Mental Health

SEIZURE DISORDERS

SEIZURE DISORDERS

SEIZURE DISORDERS.

Seizure is defined as when there is a non-recurrent abnormal electrical activity in the brain or central nervous system resulting in abnormal motor, sensory or psychomotor experiences.

A seizure is an abnormal, unregulated electrical discharge that occurs within the brain’s cortical gray matter and gradually interrupts normal brain function.

Therefore when a person has recurrent, intermittent tendency to develop a seizure, we say he is having epilepsy.

  • A seizure causes altered awareness, abnormal sensations, focal involuntary movements, or convulsions (widespread violent involuntary contraction of voluntary muscles).
  • About 2% of adults have a seizure at some time during their life. Two thirds of these people never have another one.
  • Seizure disorders are either epileptic or non-epileptic.

Epileptic seizures:

Epilepsy is a neurological disorder in which the brain activity becomes abnormal, causing seizures or periods of unusual behaviour, sensations, and sometimes loss of awareness.

Epilepsy (also called epileptic seizure disorder) is a chronic brain disorder characterized by recurrent seizures that are unprovoked (ie, not related to reversible stressors) and that occur > 24 h apart.

 A single seizure is not considered an epileptic seizure. Epilepsy is often idiopathic, but various brain disorders, such as malformations, strokes, and tumors, can cause symptomatic epilepsy.

Symptomatic epilepsy is epilepsy due to a known cause (eg, brain tumor, stroke). The seizures it causes are called symptomatic epileptic seizures. Such seizures are most common among neonates (see Neonatal Seizure Disorders) and the elderly.

 

Cryptogenic epilepsy is epilepsy assumed to be due to a specific cause, but whose specific cause is currently unknown.

Non epileptic seizures.

These are provoked by a temporary disorder or stressor (eg, metabolic disorders, CNS infections, cardiovascular disorders, drug toxicity or withdrawal, psychogenic disorders). In children, fever can provoke a seizure (febrile seizures).

 

Psychogenic nonepileptic seizures (pseudoseizures) are symptoms that simulate seizures in patients with psychiatric disorders but that do not involve an abnormal electrical discharge in the brain.

causes of epilepsy

Etiology of Seizure Disorders:

I. Age-Specific Causes:

A. Before Age 2:

  • Fever: Seizures in young children often result from fevers, a common occurrence in this age group.
  • Birth or Developmental Defects: Structural abnormalities present at birth or developmental issues contribute to seizures.
  • Birth Injuries: Trauma during the birthing process can lead to seizure disorders in infants.
  • Metabolic Disorders: Disorders affecting metabolism may manifest as seizures in early childhood.

B. Ages 2 to 14:

  • Idiopathic Seizure Disorders: Seizures with no identifiable cause, often occurring during childhood, fall under idiopathic seizure disorders.

C. Adults:

  • Cerebral Trauma: Traumatic brain injuries, often resulting from accidents, can trigger seizures in adults.
  • Alcohol Withdrawal: Abrupt cessation of alcohol intake can lead to seizures as the body adjusts.
  • Tumors: The presence of tumors in the brain may cause seizures, especially in adults.
  • Strokes: Disruption of blood flow to the brain, resulting in a stroke, is a significant cause of seizures in adults.
  • Unknown Cause (50%): In many cases, the cause of seizures in adults remains unidentified, highlighting the complexity of diagnosis.

D. The Elderly:

  • Tumors: Tumors in the brain become a more prominent cause of seizures in the elderly.
  • Strokes: Similar to adults, strokes are a common contributor to seizures in the elderly.

E. Reflex Epilepsy: 

  • Seizures are predictably triggered by external stimuli, such as lights, sounds, or touch, in rare cases known as reflex epilepsy.

F. Cryptogenic and Refractory Epilepsy:

  • Anti-NMDA receptor encephalitis, particularly in young women, is identified as a rare cause, leading to psychiatric symptoms and movement disorders. Ovarian teratoma is associated with this condition.

II. General Causes of Seizures Irrespective of Age:

  • Autoimmune Disorders: Cerebral vasculitis, anti-NMDA receptor encephalitis, and multiple sclerosis may lead to seizures, although rarely.
  • Cerebral Edema: Swelling of the brain tissue, known as cerebral edema, can trigger seizures.
  • Eclampsia, Hypertensive Encephalopathy: Conditions related to high blood pressure during pregnancy can result in seizures.
  • Cerebral Ischemia or Hypoxia: Insufficient blood flow or oxygen to the brain may cause seizures.
  • Cardiac Issues, Carbon Monoxide Toxicity, and Stroke: Conditions affecting the heart, carbon monoxide exposure, drowning, suffocation, and strokes are potential triggers.
  • Head Trauma: Both birth-related injuries and traumatic injuries during life can contribute to seizure disorders.
  • CNS Infections: AIDS, brain abscess, malaria, meningitis, neurocysticercosis, neurosyphilis, rabies, tetanus, toxoplasmosis, and viral encephalitis can lead to seizures.
  • Congenital or Developmental Abnormalities: Structural abnormalities present from birth or those developing during early life contribute to seizures.
  • Drugs and Toxins: Various substances, including drugs and toxins like camphor, ciprofloxacin, cocaine, and others, may induce seizures.
  • Expanding Intracranial Lesions: Hemorrhage, hydrocephalus, and tumors contribute to seizures by causing pressure on the brain.
  • Hyperpyrexia: Extremely high fever, associated with drug toxicity or heatstroke, can lead to seizures.
  • Metabolic Disturbances: Hypocalcemia (linked to hypoparathyroidism), hypoglycemia, and hyponatremia.
  1. Less Common Causes: Aminoacidurias, hepatic or uremic encephalopathy, hyperglycemia, hypomagnesemia, hypernatremia.
  2. Neonatal Cause: Vitamin B6 (pyridoxine) deficiency in neonates.
  • Withdrawal Syndromes: Alcohol, anesthetics, barbiturates, benzodiazepines—withdrawal from these substances can induce seizures.
seizure anticonvulsants

Classification of Seizures

Seizures are classified as generalized or partial.

1. Partial seizures/focal seizures.

In partial seizures, the excess neuronal discharge occurs in one cerebral cortex, and most often results from structural abnormalities.

 Partial seizures may be;

  • Simple : Focal seizures without impairment of consciousness or awareness.
  • Complex : Focal seizures with impairment of consciousness or awareness.

Partial seizures may evolve into a generalized seizure (called secondary generalization), which causes loss of consciousness. Secondary generalization occurs when a partial seizure spreads and activates the entire cerebrum bilaterally. Activation may occur so rapidly that the initial partial seizure is not clinically apparent or is very brief.

Symptoms and Signs of partial seizures.

The manifestation depends on the part of the brain that is affected;

A. Simple Partial Seizures:

  • Aura: Simple partial seizures may begin with auras, such as motor activity, sensory sensations, autonomic changes, or psychic experiences. Auras are simple partial seizures that begin focally. Auras may consist of motor activity or sensory, autonomic, or psychic sensations (eg, paresthesias, a rising epigastric sensation, abnormal smells, a sensation of fear, a déjà vu sensation).
  • Most seizures end spontaneously in 1 to 2 min.
  • Postictal State: Following generalized seizures, a postictal state occurs, characterized by deep sleep, headache, confusion, and muscle soreness; this state lasts from minutes to hours. 
  • Most patients appear neurologically normal between seizures, although high doses of the drugs used to treat seizure disorders, particularly anticonvulsants, can reduce alertness.

B. Jacksonian Seizures:

  • In Jacksonian seizures, focal motor symptoms begin in one hand and then march up the arm (Jacksonian march). Other focal seizures affect the face first, and then spread to an arm and sometimes a leg. Some partial motor seizures begin with an arm raising and the head turning toward the raised arm (called fencing posture).

C. Complex Partial Seizures:

Complex partial seizures are often preceded by an aura. During the seizure, patients may stare. Consciousness is impaired, but patients have some awareness of the environment (eg, they purposefully withdraw from noxious stimuli). The following may also occur:

  • Oral automatisms (involuntary chewing or lip smacking)
  • Limb automatisms (eg, automatic purposeless movements of the hands)
  • Utterance of unintelligible sounds without understanding what they say
  • Resistance to assistance
  • Tonic or dystonic posturing of the extremity contralateral to the seizure focus
  • Head and eye deviation, usually in a direction contralateral to the seizure focus
  • Bicycling or pedaling movements of the legs if the seizure emanates from the medial frontal or orbitofrontal head regions
  • Motor symptoms subside after 1 to 2 min, but confusion and disorientation may continue for another 1 or 2 min. 
  • Postictal amnesia is common.
  • Patients may lash out if restrained during the seizure or while recovering consciousness if the seizure generalizes. However, unprovoked aggressive behavior is unusual.
  • Left temporal lobe seizures may cause verbal memory abnormalities; right temporal lobe seizures may cause visual spatial memory abnormalities.

Generalized seizures

In generalized seizures, abnormal electrical discharge diffusely involves the entire cortex of both hemispheres from the onset, and consciousness is usually lost. Generalized seizures result mostly from metabolic disorders and sometimes from genetic disorders. 

Generalized seizures include the following:

1. Infantile spasms: Characterized by sudden flexion and adduction of the arms and forward flexion of the trunk. Seizures last a few seconds and recur many times a day. They occur only in the first 5 years of life, then are replaced by other types of seizures. Developmental defects are usually present.

2. Typical absence seizures (formerly called petit mal seizures): Consist of a 10- to 30-second loss of consciousness with eyelid fluttering; axial muscle tone may or may not be lost. Patients do not fall or convulse; they abruptly stop activity, then just as abruptly resume it, with no postictal symptoms or knowledge that a seizure has occurred. Absence seizures are genetic and occur predominantly in children. Without treatment, such seizures are likely to occur many times a day. Seizures often occur when patients are sitting quietly, can be precipitated by hyperventilation, and rarely occur during exercise. Neurologic and cognitive examination results are usually normal.

3. Atypical absence seizures: Usually occur as part of the Lennox-Gastaut syndrome, a severe form of epilepsy that begins before age 4 years. They differ from typical absence seizures in the following ways:

  • They last longer.
  • Jerking or automatic movements are more pronounced.
  • Loss of awareness is less complete.
  • Many patients have a history of damage to the nervous system, developmental delay, abnormal neurologic examination results, and other types of seizures. Atypical absence seizures usually continue into adulthood.

4. Atonic seizures: Occur most often in children, usually as part of Lennox-Gastaut syndrome. Atonic seizures are characterized by a brief, complete loss of muscle tone and consciousness. Children fall or pitch to the ground, risking trauma, particularly head injury.

5. Tonic seizures: Occur most often during sleep, usually in children. The cause is usually the Lennox-Gastaut syndrome. Tonic (sustained) contraction of axial muscles may begin abruptly or gradually, then spread to the proximal muscles of the limbs. Tonic seizures usually last 10 to 15 seconds. In longer tonic seizures, a few rapid clonic jerks may occur as the tonic phase ends.

6. Tonic-clonic seizures: Can be primarily generalized or secondarily generalized.

  • Primarily generalized seizures typically begin with an outcry, followed by a loss of consciousness, falling, tonic contraction, and then clonic (rapidly alternating contraction and relaxation) motion of muscles of the extremities, trunk, and head. Urinary and fecal incontinence, tongue biting, and frothing at the mouth sometimes occur. Seizures usually last 1 to 2 minutes, and there is no aura.
  • Secondarily generalized tonic-clonic seizures begin with a simple partial or complex partial seizure and then progress to resemble other generalized seizures.

7. Myoclonic seizures: Brief, lightning-like jerks of a limb, several limbs, or the trunk. They may be repetitive, leading to a tonic-clonic seizure. The jerks may be bilateral or unilateral. Unlike other seizures with bilateral motor movements, consciousness is not lost unless the myoclonic seizure progresses into a generalized tonic-clonic seizure.

8. Juvenile myoclonic epilepsy: An epilepsy syndrome characterized by myoclonic, tonic-clonic, and absence seizures. It typically appears during adolescence. Seizures begin with a few bilateral, synchronous myoclonic jerks, followed in 90% of cases by generalized tonic-clonic seizures. They often occur when patients awaken in the morning, especially after sleep deprivation or alcohol use. Absence seizures may occur in one-third of patients.

GENERAL MANAGEMENT OF SEIZURE DISORDERS.

During the attack; (first aid)

  1. Ensure Safety:

    1. Observe warning signs.

    2. Lay the individual on a flat surface.

    3. Ensure the surrounding environment is safe.

  2. Remove Hazards: Clear the area of dangerous objects like sticks or stones.
  3. Do Not Restrain: Avoid restraining the person during the seizure.
  4. Protect Airways: Do not insert anything into the mouth.
  5. Note Duration: Record the length of the seizure for medical evaluation.
  6. Post-Seizure:

    • Allow the person to rest.

    • Provide refreshments if needed.

Drug Management:

  1. Anticonvulsant Medications:

  • Use medications such as diazepam, phenytoin, sodium valproate, among others.
  • Follow prescribed dosage and administration schedules.

Severe Epileptic Attack (Pediatric/Medical/Psychiatric Emergency):

  1. Anticonvulsant Administration: Administer appropriate anticonvulsants promptly.
  2. Cardio-Respiratory Support: Provide immediate support for cardiac and respiratory functions.
  3. Prevent Falling: Ensure a safe environment to prevent injuries during seizures.
  4. Intravenous Fluids: Administer intravenous fluids to maintain hydration.
  5. Hypoglycemia Prevention: Monitor and maintain blood glucose levels to prevent hypoglycemia.

Long-Term Management:

  1. Individualized Treatment Plans: Develop a personalized treatment plan in collaboration with healthcare professionals.
  2. Regular Medication Adherence: Ensure consistent adherence to prescribed anticonvulsant medications.
  3. Lifestyle Modifications: Encourage a healthy lifestyle with regular sleep patterns, stress management, and a balanced diet.
  4. Trigger Identification: Identify and manage potential triggers, such as stress or lack of sleep.
  5. Seizure Action Plan: Establish a comprehensive seizure action plan in coordination with healthcare providers.
  6. Regular Medical Follow-Up: Schedule routine medical follow-ups to monitor progress and adjust treatment as needed.
  7. Educational Support: Provide educational resources and support for individuals and their families to understand and cope with epilepsy.
  8. Psychosocial Interventions: Integrate psychosocial interventions to address emotional and psychological aspects of living with epilepsy.
  9. Emergency Medication Access: Ensure accessibility to emergency medications in case of prolonged seizures.
  10. Multidisciplinary Approach: Involve a multidisciplinary team, including neurologists, psychologists, and social workers, for holistic care.

Nursing Interventions for Seizure Disorder

Prevent Trauma/Injury:

  • Teach caregivers to recognize warning signs and manage patients during and after seizures.
  • Advise against using breakable thermometers; opt for tympanic thermometers when necessary.
  • Maintain strict bedrest during prodromal signs or auras.
  • Turn the head to the side, suction the airway as needed, and provide support during seizures.
  • Avoid restraint attempts; monitor and document antiepileptic drug (AED) levels, side effects, and seizure frequency.

Promote Airway Clearance:

  • Keep the patient in a lying position on a flat surface.
  • Turn the head to the side during seizure activity.
  • Loosen clothing around the neck, chest, and abdomen.
  • Perform suctioning as needed.
  • Supervise supplemental oxygen or bag ventilation postictally.

Improve Self-Esteem:

  • Assess individual situations contributing to low self-esteem.
  • Avoid over-protectiveness; encourage independence.
  • Support and monitor activities; consider the attitudes and capabilities of significant others.
  • Help individuals understand that their feelings are normal, discouraging guilt and blame.

Enforce Education About the Disease:

  • Review the pathology and prognosis of the condition.
  • Emphasize the lifelong need for treatments.
  • Identify specific trigger factors (flashing lights, hyperventilation, loud noises, video games, TV).
  • Stress the importance of good oral hygiene and regular dental care.
  • Educate on the medication regimen, emphasizing adherence and the significance of not discontinuing therapy without physician supervision.
  • Provide clear instructions for missed doses.

Seizure Documentation:

  • Maintain detailed records of seizure occurrences, duration, and characteristics.
  • Document any changes in the patient’s behavior or aura.

Family Education and Support:

  • Educate family members on seizure first aid and safety measures.
  • Offer emotional support and counseling to both the patient and family members.

Regular Neurological Assessments:

  • Perform routine neurological assessments to monitor changes in seizure patterns or neurological status.

Medication Administration:

  • Administer antiepileptic medications as prescribed, ensuring proper dosage and adherence.

Lifestyle Modifications:

  • Collaborate with the patient to identify and manage lifestyle factors that may trigger seizures.
  • Encourage the establishment of consistent sleep patterns and stress reduction techniques.

Emergency Preparedness:

  • Ensure caregivers are equipped to handle emergencies, providing guidance on when to seek medical attention.

Social Integration:

  • Assist in facilitating social integration for the patient, addressing any potential stigma or discrimination.

FEBRILE CONVULSIONS 

A febrile seizure, also known as a fever fit, is a seizure associated with a high body temperature without any serious underlying health issue.

Primarily occurs in children aged 6 months to 5 years. Usually, seizures last less than five minutes, and the child returns to normal within sixty minutes.

Causes:

  • Familial predisposition to febrile seizures.
  • Linked to fevers exceeding 38 °C (100.4 °F), often triggered by viral illnesses. The risk increases with the height of the temperature.
  • Vaccines, although with a small associated risk, may contribute, including measles/mumps/rubella/varicella, diphtheria/tetanus/acellular pertussis/polio/Haemophilus influenzae type b, and others.

Types:

Simple Febrile Seizures:

  • Short duration (<15 minutes), no focal features.
  • Usually, a single tonic-clonic seizure in a 24-hour period.

Complex Febrile Seizures:

  • Last longer than 15 minutes or occur multiple times within 24 hours.
  • May have focal features.

Febrile Status Epilepticus:

  • Lasts for more than 30 minutes.
  • Occurs in up to 5% of febrile seizure cases.

Diagnosis:

  • Generally clinical, eliminating serious causes such as meningitis and encephalitis.
  • Blood tests, brain imaging, and EEG are typically not required.
  • Verify absence of brain infection, metabolic issues, and prior seizures unrelated to fever.

Management:

First Aid During Seizure:

  • Ensure a safe environment.
  • Remove dangerous objects.
  • Do not restrain the child.
  • Note seizure duration.

Medical Intervention:

  • No routine use of anti-seizure or anti-fever medications.
  • Benzodiazepines (e.g., lorazepam) for seizures lasting over five minutes.

Treatment:

  • Maintain a calm environment.
  • Note seizure start time; call an ambulance if >5 minutes.
  • Place the child on a protected surface.
  • Do not restrain; position on the side to prevent choking.
  • Seek immediate medical attention, especially if the first seizure or concerning symptoms persist.
  • Intravenous lorazepam for prolonged seizures.

Prevention:

  • Proper fever management in children.
  • Avoid exposing babies to excessive heat.

SEIZURE DISORDERS Read More »

Autism Spectrum Disorder

Autism Spectrum Disorder

AUTISM

Autism, also known as autistic spectrum disorder, is a childhood psychiatric disorder characterized by communication impairment, social interaction impairment, and restricted and repetitive activities.

Causes of Autism

  • IDIOPATHIC The exact cause of autism is still unknown,

But it is believed to result from a combination of genetic and environmental factors. 

  • Genetic Factors: Genetic factors are believed to play a significant role in autism. Numerous studies have shown that there is a higher risk of developing autism if a family member has the condition. Certain genes have been identified as potential contributors to the development of autism, although no single gene has been identified as the sole cause. It is likely that multiple genes, in combination with other factors, contribute to the development of ASD.

  • Neurotransmitter Imbalances: Imbalances in neurotransmitters, the chemical messengers in the brain, have been implicated in autism. Specifically, abnormalities in the levels or functioning of neurotransmitters such as serotonin, dopamine, and gamma-aminobutyric acid (GABA) have been observed in individuals with ASD. These imbalances may affect brain development and the regulation of mood, behavior, and social interactions.

  • Brain Development and Connectivity: Research has shown that individuals with autism may have atypical brain development and connectivity. Studies using various neuroimaging techniques have revealed differences in brain structure, function, and connectivity in individuals with ASD. These differences may affect the development and organization of neural networks involved in social interaction, communication, and sensory processing.

  • Environmental Factors: While genetic factors play a significant role, environmental factors may also contribute to the development of autism. Prenatal and early-life exposures, such as maternal infections during pregnancy, exposure to certain chemicals or medications, complications during birth, and prenatal factors like advanced parental age, have been studied as potential environmental contributors to ASD. However, the specific environmental factors and their interactions with genetic factors are still being explored.

  • Immune System Dysfunction and Inflammation: Some research suggests that immune system dysfunction and chronic inflammation may be involved in the pathophysiology of autism. Abnormal immune responses, including alterations in cytokine levels and the presence of certain autoantibodies, have been observed in individuals with ASD. It is hypothesized that immune dysregulation and inflammation may affect brain development and contribute to the behavioral and cognitive symptoms of autism.

Classifications of Autism

According to Severity

Based on the degree of severity and level of support ASD are classified into 3 types.

Severity levelSocial communicationRestricted, repetitive behaviors
Level 3Requiring very substantial support
  • Severe deficits in verbal and non-verbal communication skills
  • Severe impairment in functioning
  • Very limited initiation of social interactions
  • Minimal response to social overtures from others
  • Inflexibility of behavior
  • Extreme difficulty in coping with change
  • Repeated behavior markedly interferes with functioning in all spheres
  • Great distress/difficulty changing focus or action
Level 2Requiring substantial support
  • Marked deficits in verbal and non-verbal communication skills
  • Marked impairment in functioning
  • Limited initiation of social interactions
  • Difficulty in coping with change
  • Distress/difficulty changing focus or action
  • Repetitive behaviors occur frequently
Level 1Requiring support
  • Without support, deficits in verbal and non-verbal communication skills
  • Atypical and unusual social responses
  • Interference with functioning in one or more context
  • Problems of organization and planning hamper independence
According to Diagnostic Criteria

Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 

  1. Autistic Disorder (Classic Autism): Autistic disorder, also known as classic autism, is the most severe and well-known type of autism. Individuals with this type of autism typically exhibit significant social, communication, and behavioral challenges. They may have delayed language development, difficulty with social interactions, repetitive behaviors, and a limited range of interests.

  2. Asperger’s Syndrome: Asperger’s syndrome is considered a milder form of autism. Individuals with Asperger’s syndrome generally have average or above-average intelligence but struggle with social interactions and nonverbal communication. They may have intense interests in specific subjects and may exhibit repetitive behaviors or routines.

  3. Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS): PDD-NOS is a classification used when an individual displays some, but not all, of the characteristics associated with autism. People with PDD-NOS may have difficulties with social communication, interaction, and behavior, but the symptoms may not fully meet the criteria for autistic disorder or Asperger’s syndrome.

  4. Childhood Disintegrative Disorder (CDD): Childhood disintegrative disorder is a rare condition in which children develop typically for a period of time but then experience a significant loss of previously acquired skills. These skills may include language, social abilities, and motor functions. CDD usually occurs between the ages of 2 and 4, and the cause is not well understood.

  5. Rett Syndrome: Rett syndrome is a genetic disorder that primarily affects females. It is characterized by normal development in early childhood, followed by a regression in skills and the emergence of specific symptoms such as loss of purposeful hand skills, repetitive hand movements, and difficulties with language and social interactions.

Signs and Symptoms

Social interaction impairment:

  • Failure to respond to the name
  • Preference for playing in isolation
  • Reduced interest in other people
  • Lack of eye contact
  • Physically aggressive behavior
  • Self-injurious behaviors due to frustration (e.g., biting oneself)

Communication impairment:

  • Poor language development
  • Lack of communication gestures
  • Mute
  • Issues with combining words in speech
  • Failure to respond to their name

Repetitive and restricted behaviors:

  • Preoccupation with certain objects and mannerisms
  • Resistance to change
  • Overreaction or underreaction to one or more senses

Management of Autism

Aims of management

  • Promoting Communication and Social Interaction
  • Reducing Challenging Behaviors
  • Supporting Cognitive and Behavioral Development

  1. Early Intervention: Early identification and intervention are important in optimizing outcomes for individuals with autism. Nurses and medical team do evaluations, and initiate appropriate interventions as early as possible.

  2. Behavioral Therapies: Behavioral therapies, such as Applied Behavior Analysis (ABA), are often utilized in the management of autism. These therapies focus on modifying behaviors, teaching new skills, and promoting positive interactions. Nurses may collaborate with behavior analysts and therapists to implement and monitor these interventions.

  3. Speech and Language Therapy: Communication difficulties are common in individuals with autism. Speech and language therapy can help improve language development, communication skills, and social interaction. Nurses may provide support and resources to families to ensure consistent follow-up and participation in therapy sessions.

  4. Medications: In some cases, medications may be prescribed to manage specific symptoms associated with autism, such as hyperactivity, anxiety, or aggression. Nurses play a role in monitoring medication effectiveness, side effects, and educating families about proper administration.

  5. Family Support and Education: Providing support and education to families is crucial in the management of autism. Nurses can offer guidance on coping strategies, community resources, and access to support groups. They can also provide families with accurate and up-to-date information about autism and advocate for their needs within healthcare and educational settings.

  6. Individualized Care Plans: Individualized care plans are essential in managing autism. Nurses collaborate with families, educators, and therapists to develop personalized plans that address the unique strengths and challenges of each individual. These plans may include specific goals, strategies, and accommodations to optimize the individual’s functioning and well-being.

  7. Continue with, 
  8.  Use simple and short sentences during conversations when interviewing the patient and the parents.
  9. Develop a trusting relationship with the child and convey acceptance of the child separate from the unacceptable behavior.
  10. Develop a symptom management plan for the child, including obtaining developmental milestones, improving communication skills, promoting good social interaction skills, enhancing the child’s interests, and reducing repetitive behaviors.
  11. Create tasks with a high chance of success, such as guided play and introducing stimulative activities with rewards.
  12. Train social skills and reward positive behaviors like good eye contact, smiling, and helping others.
  13. Introduce one activity at a time and be specific while teaching skills.
  14. Ensure the child’s attention by calling their name and establishing eye contact before giving instructions.
  15. Repeat instructions, provide explanations and clarifications, and avoid assuming understanding.
  16. Simplify activities and teaching techniques when necessary.
  17. Provide assistance during task performance.
  18. Be patient and tolerant.
  19. Gradually decrease assistance and the number of assistants, while assuring the patient that assistance is still available when necessary.
  20. Coordinate overall treatment plans with schools, collateral personnel, the child, and the family.
  21. Assess parenting skill levels, considering intellectual, emotional, physical strengths, and limitations.
  22. Be sensitive to parents’ needs as they often experience exhaustion of parental resources due to prolonged coping with the child.
  23. Provide information and materials related to the child’s disorder and effective parenting techniques to the parents or guardians, using written or verbal step-by-step explanations.
  24. Educate the child and family on the use of psycho stimulants and practice strategies for dealing with the child’s behaviors.
Nursing Interventions when caring for a child with Autism.

  1. Promote Communication Skills: Encourage and support the development of communication skills by using visual aids, augmentative and alternative communication (AAC) devices, and social stories. Provide a communication-friendly environment and use simple and concise language to facilitate understanding.

  2. Implement Structure and Routine: Establish consistent routines and visual schedules to provide predictability and reduce anxiety. Help the child understand and follow daily routines through visual cues and verbal prompts.

  3. Manage Sensory Sensitivities: Create a sensory-friendly environment by reducing excessive noise, bright lights, and other sensory triggers. Offer sensory breaks or provide sensory tools like fidget toys or weighted blankets to help the child self-regulate.

  4. Support Social Interaction: Facilitate social interactions by creating opportunities for the child to engage with peers, such as structured play activities or social groups. Teach and reinforce appropriate social skills, such as sharing, taking turns, and making eye contact.

  5. Provide Emotional Support: Recognize and address the emotional needs of the child with ASD. Use calming techniques, such as deep breathing exercises or sensory input, to help manage anxiety or emotional distress.

  6. Collaborate with the Multidisciplinary Team: Work closely with the child’s healthcare team, including therapists, psychologists, and educators, to ensure coordinated and comprehensive care. Share relevant information and collaborate on treatment plans and interventions.

  7. Educate the Family: Provide education and support to the child’s family, including information about ASD, available resources, and strategies for managing challenges at home. Help them access support groups or connect with other families in similar situations.

  8. Assist with Medication Management: If medications are prescribed, educate the family about the purpose, potential side effects, and proper administration of medications. Monitor the child’s response to medication and communicate any concerns to the healthcare provider.

  9. Facilitate Self-Care Skills: Teach and encourage age-appropriate self-care skills, such as grooming, dressing, and feeding. Use visual cues and step-by-step instructions to assist the child in developing independence and promoting self-confidence.

  10. Advocate for the Child: Serve as an advocate for the child with ASD and ensure their needs are met in various settings, such as school, community, and healthcare settings. Communicate with teachers, caregivers, and other professionals to promote understanding and inclusion.

Nursing Diagnosis

You can formulate nursing diagnosis from the following issues.

  1. Impaired Social Interaction: This nursing diagnosis reflects difficulties in initiating or maintaining social interactions, limited eye contact, and challenges in understanding social cues and norms.

  2. Impaired Verbal Communication: Many individuals with autism experience delays or difficulties in speech and language development, which may lead to impaired verbal communication. This diagnosis addresses challenges in expressing needs, understanding and using language, and engaging in effective communication.

  3. Impaired Nonverbal Communication: Individuals with autism may struggle with nonverbal communication skills, such as body language, facial expressions, and gestures. This diagnosis focuses on difficulties in understanding and utilizing nonverbal communication.

  4. Risk for Injury: Individuals with autism may engage in repetitive or self-injurious behaviors, pose safety risks due to sensory-seeking or sensory-avoiding behaviors, or have difficulty recognizing and responding to potential dangers. This diagnosis addresses the increased risk of injury or harm.

  5. Anxiety: Many individuals with autism experience anxiety and heightened levels of stress due to difficulties with communication, social interactions, and sensory sensitivities. This diagnosis focuses on the individual’s feelings of apprehension, restlessness, and increased stress levels.

  6. Impaired Coping: This nursing diagnosis addresses challenges in effectively managing stress, regulating emotions, and adapting to changes or transitions. Individuals with autism may exhibit maladaptive coping mechanisms or have difficulty adjusting to new situations.

  7. Disturbed Sleep Pattern: Sleep disturbances, including difficulties with falling asleep, staying asleep, or having irregular sleep patterns, are common among individuals with autism. This diagnosis relates to disruptions in the normal sleep-wake cycle.

  8. Impaired Self-Care: Some individuals with autism may require assistance with various aspects of self-care, including grooming, dressing, and feeding. This diagnosis addresses difficulties in performing activities of daily living independently.

  9. Parental Role Conflict/Stress: This nursing diagnosis acknowledges the potential challenges and stress experienced by parents or caregivers of individuals with autism. It encompasses the emotional, physical, and psychological impact on parents or caregivers in managing the care of a child with ASD.

Autism Spectrum Disorder Read More »

Anxiety Disorders

Anxiety Disorders

ANXIETY DISORDERS

All children have worries and fears from time to time. Whether it’s the monster in the closet, the big test at the end of the week, or any other thing, kids have things that make them anxious, just like adults.

But sometimes anxiety in children crosses the line from normal everyday worries to a disorder that gets in the way of the things they need to do. It can even keep them away from enjoying life as they should.

How can to tell if the child’s anxieties might be more than just passing worries and fears? Here are some questions to ask oneself:

  • Are they expressing worry or showing anxiety on most days, for weeks at a time?
  • Do they have trouble sleeping at night? If you aren’t sure (they might not tell you), do you notice that they seem unusually sleepy or tired during the day?
  • Are they having trouble concentrating?
  • Do they seem unusually irritable or easy to upset?

There are several different types of anxiety disorders that can affect children. The most common include:

Generalized Anxiety Disorder (GAD)

Children and adolescents with generalized anxiety disorder have persistent, excessive, and unrealistic worries that are not focused on a specific object or situation. A child may worry excessively about his or her;

  • performance at school or in activities such as sports
  • about personal safety and that of family members,
  • or about natural disasters.

Children with generalized anxiety have a hard time “turning off” their worrying, which leads to difficulty concentrating, learning, and participating in social situations. Some children may be insecure and frequently seek reassurance, while others may be self-conscious, self-doubting, or overly concerned about meeting other people’s expectations. Generalized anxiety disorder typically affects school-aged children and adolescents.

Kids with GAD may experience physical symptoms because they are so overwhelmed by their worries;

  • headaches 
  • isolating themselves
  • avoiding school
  • Avoiding friends.

Panic Disorder

A panic attack is a sudden, intense episode of anxiety with no apparent outside cause.

Some children or adolescents may experience extreme discomfort or fear when in certain situations or places, resulting in a panic attack.

Symptoms may include;

  • shortness of breath
  • pounding heart
  • Tingling sensations throughout the body.
  • Child may tremble or feel dizzy or numb. (If your child is hyperventilating, try to have them breathe slowly with nice deep breaths.)

Although severe anxiety may result in a panic attack, a child with panic disorder often has symptoms of panic without any apparent trigger. Unlike the occasional, mild worries children often experience.

 A panic attack may dramatically affect a child’s life by interrupting his or her normal activities. Often, a child becomes preoccupied with worry about possible future attacks. Panic disorder tends to begin during adolescence, although it may start during childhood, and sometimes runs in families.

Separation Anxiety Disorder

Most children have some level of separation anxiety as its a normal phase of development in babies and toddlers. Even older children may get clingy with their parents or caregivers occasionally, especially in new settings.

But older children who get unusually upset when leaving a parent or someone else close to them, who have trouble calming down after saying goodbye, or who get extremely homesick and upset when away from home at school, camp, or play dates, may have separation anxiety disorder.

Children with separation anxiety disorder experience significant fear and distress about being away from home or their caregivers. This fear affects a child’s ability to function socially and academically. For example, a child may have a hard time making friends or maintaining relationships because he or she refuses to go on play dates without a parent, or sleep without being near a parent or caregiver.

Social Phobia

Social phobia, also known as social anxiety disorder, is an excessive fear of being rejected, humiliated, or embarrassed in front of others. A child with social phobia feels severe anxiety and self-consciousness in normal, everyday, social situations. This is more than just shyness.

The socially anxious child is terrified that they will embarrass themselves when talking with classmates, answering a question in class, or doing other normal activities that involve interacting with others.

This fear can keep the child from participating in school and activities. Some children may even find themselves unable to talk at all in some situations.

Children and adolescents with social phobia worry about a wide range of situations, such as;

  • speaking in front of a group
  • participating in class
  • talking to adults or peers
  • starting or joining in conversations
  • eating in public.
  • They may fear unfamiliar people
  • have difficulty making friends
  • can also be limited to specific situations e.g. adolescents may fear dating and recreational events, for instance
  • but they may be confident in academic and work settings.

Children and teenagers with social phobia typically avoid the situations they fear—by staying home from school or shunning parties, for instance. Although the condition can occur in children as young as age four, it is more common among adolescents. The average age of onset is 13.

Obsessive-Compulsive Disorder 

Children with obsessive-compulsive disorder (OCD) have obsessions ie; these are intrusive, unwanted thoughts. To relieve the anxiety associated with those thoughts, they perform compulsions, or repetitive actions, rituals, or routines.

 Compulsions may involve washing, counting, organizing objects, or reading a passage of text over and over.

For children with OCD, these thoughts and behaviors significantly interfere with their daily functioning and can cause distress and embarrassment. OCD can develop at any age, but it’s most likely to occur between the ages of 8 and 12, in late adolescence, or early adulthood.

Specific Phobias     

Fears are common in childhood and are usually outgrown as a child matures. For some children and teens, however, fears can become severe. If a fear is excessive and persistent it may be a phobia, or an intense irrational fear of a specific object or situation.

Phobias differ from usual fears in that they don’t decrease with reassurance, and they interfere with a child’s life. Children may develop phobias as early as age five. Specific phobias commonly involve animals, insects, heights, thunder, driving, dental or medical procedures, elevators etc.

Selective Mutism

Children with selective mutism speak freely in familiar situations but become mute in specific situations or around certain people. Some children with selective mutism may avoid eye contact and refuse to communicate with others. Others may enjoy the company of others but remain silent or have a close friend speak for them. Selective mutism typically affects preschool-aged children and those in elementary school, usually before age 10.

Management

Mental health professionals today understand much more about childhood anxiety disorders than in the past. No matter what the child’s anxiety disorder is, a professional health worker  can help.

but the care giver has to be advised about the following for the child at home by being supportive and understanding.

  • If the child becomes upset and anxious, stay calm and talk to them through it.
  • Don’t punish the child for things like mistakes on schoolwork or lack of progress.
  • “Catch” them doing well: Praise even small accomplishments, and be specific.
  • Plan for transitions. If the child’s anxiety means going to school in the morning is very stressful, allow plenty of extra time.
  • While respecting  the child’s privacy, do give their teachers and coaches information they need to help them understand what’s going on.

Above all, be available to listen when the child wants to talk to you about their anxiety. Kids with anxiety disorders often try to hide their fears because they think you won’t understand. So let the child know you’re ready to listen whenever they’re ready to talk

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Mental Retardation

Mental Retardation

Mental Retardation

Mental retardation is a generalized neurodevelopment disorder characterised by significantly impaired intellectual and adaptive disorder present before age of 18yrs.

Mental retardation refers to significantly sub-average general intellectual functioning resulting in or associated with concurrent impairments in adaptive behaviour as manifested during the developmental period

This is characterised by below mental ability and average intelligence or lack of skills necessary for day to day living. People with mental retardation can and do learn new skills, but they learn them more slowly.

People with intellectual disability have the following limitations

  • Intellectual functioning also known as (intelligence quotient) IQ

This refers to a person’s ability to learn reason, make decisions, and solve problems.  Intelligence quotient is measured test of which the average is 100 and a person is considered intellectually disabled if the IQ is less than 70%

  • Adaptive behaviours

These are degrees with which the individual meets the standards of personal dependence and social responsibility expected of his age and cultural group.

These are skills necessary for day to day life such as being able to communicate effectively, interact with others and take care of one’s self.

Classification of Mental Retardation

Intelligence quotient is the ratio between mental age (MA) and chronological age (CA) where chronological age is determined from the date of birth and mental age is determined by the intelligence tests.

  • Mild mental retardation
  • Moderate mental retardation
  • Severe mental retardation
  • Profound
Mild mental retardation (educable)

These have IQ levels ranging from 50 to 69%. These children go undiagnosed until they reach school years. They are often slower to talk, walk and feed themselves as compared to other children. They can learn domestic and practical skills including reading and maths and achieve good independence in self-care like eating, washing, dressing etc. They can build social and job skills and can live on their own.

 

Moderate mental retardation (trainable)

These have IQ ranging from 35 to 49%.

Children with mild mental retardation show noticeable delays in developing speech and motor skills. Although they are unlikely to acquire useful academic skills, they can learn basic communication, some health and safety habits and other simple skills. They cannot learn how to read or do maths. Moderately retarded adults cannot live alone and need supervision throughout life but can do simple tasks and travel alone to familiar places.

Severe mental retardation (dependent retarded)

These have IQ ranging from 20 to 34%

This condition can be diagnosed as early as at birth or very soon after birth. By preschool age, they show delays in motor development and little or no ability to communicate. With good training, they can learn self-help skills such as how to feed or bath themselves. They usually learn to walk and gain basic understanding of speech as they get older.

Adults with severe mental retardation may be able to follow daily routines but need through supervision and to be kept in a protected environment.

Profound mental retardation (life support)

Only a few people with mental retardation have IQ below 20%.

This condition is diagnosed at birth and is associated with other medical problems which require nursing care. The children show delays in all aspects of development.

Most individuals are immobile, have limited ability to understand, are unable to care for themselves, have various neurological and physical disabilities, visual and hearing abilities are impaired and so many other associated disabilities.

Causes of Mental Retardation

Mental retardation is a complex action which may be caused by interaction of many factors and in 75% of patients, the cause is unknown.

Genetic factors

  • If one or both parents have mental retardation, chances that children develop this condition are high.
  • Sometimes mental retardation is caused by abnormalities of chromosomes rather than individual genes e.g. down syndrome where an individual has an extra chromosome in the cell.

Problems during pregnancy

  • Infections in pregnancy like TORCHES; toxoplasmosis, Rubella, Cytomegalovirus, Syphilis, herpes simplex.
  • Alcohol in pregnancy may cause mental retardation through Fetal Alcohol Syndrome FAS
  • Placental dysfunction like toxaemia of pregnancy, placenta previa, cord prolapse etc.
  • Some drugs like cocaine when taken in pregnancy may harm mental development of unborn child.
  • Maternal malnutrition
  • Exposure to radiations

Problems during birth (perinatal factors)

  • Prematurity
  • Very low birth weight
  • Instrumental delivery
  • Prolonged labour
  • Kernicterus
  • Birth asphyxia

Problems after birth (postnatal factors)

  • Lead or mercury poisoning
  • Severe malnutrition
  • Accidents that cause severe head injury
  • Diseases such as meningitis, encephalitis etc.
  • Untreated hypothyroidism
  • Brain tumours
  • Epilepsy

Environmental causes

  • Cultural deprivation
  • Low socio-economic status
  • Inadequate caretakers
  • Child abuse

Signs and symptoms of mental retardation

These vary greatly depending on the severity of the condition

  • IQ below 70%
  • Failure to achieve developmental milestones
  • Delay in oral language development
  • Deficit in memory skills
  • Difficult learning social roles
  • Difficult with problem solving skills
  • Decreased learning abilities or inabilities to meet education demands at school
  • Limited motor and communication skills
  • Visual and hearing impairments
  • Epilepsy always accompanies the problem
  • Require constant supervision
  • Neurological disorders are very common
  • Some may have psychotic or behavioural disorders
  • Self-care is a problem to these patients.

Diagnosis

This can be made by

  1. IQ testing (MA/CA)X100
  2. Taking history from the parents or care giver
  3. Carrying out biochemical tests
  4. Physical examination
  5. Neurological examination
  6. Assessing developmental milestones
  7. Investigation
  • Urine and blood for metabolic disorders
  • Culture for biochemical studies
  • Amniocentesis in infant chromosomal disorders
  • Chorionic villi sampling
  • Hearing and speech evaluation
  • CT scan or MRI
  • Thyroid function tests when cretinism is suspected
  1. X-ray

Management of Mental Retardation

Majority of the mentally retarded children and adults are cared for at home and admission is only required because of incompetent parents, psychotic behaviours, stigmatisation etc.

Aims

  1. To enable the patient reach his or her maximum potential ability
  2. To ensure safety of the patient.
  • Mentally retarded children are admitted in hospitals or any other institution with schools that offer them training and education suitable to their abilities.
  • Physical training, recreation, and social activities also play a part in treatment regimen
  • Love, attention and care are one of the most required elements for these children
  • Written, verbal and pictorial forms of communication as well as gestures and demonstration are very helpful to ensure mutual understanding and improve treatment adherence
  • Programmes that maximise speech, language, cognition, psychomotor, social, self care and occupational skills have to be encouraged
  • The main stay of treatment is by developing a comprehensive management plan for the condition which includes multiple disciplines like special educators, language therapists, behavioural therapists, occupational therapists and community service providers that provide social support to affected families.
  • On-going evaluation for overlapping psychiatric disorders such as depression, bipolar disorder and ADHD
  • Neuroleptics such as haloperidol are given in cases of psychotic behaviour
  • Analgesics are required for management of pain especially in severe mental retardation.
  • Family therapy to help parents develop coping skills and deal with guilt and anger
  • Early intervention programs for children younger than age 3 with mental retardation
  • Provide day schooling to train the child in basic skills such as bathing and feeding
  • Vocational training
Prevention of mental retardation

Preconception

  • Genetic counselling
  • Immunisation of maternal rubella
  • Adequate maternal nutrition
  • Family planning

During gestation

  • Adequate nutrition
  • Fetal monitoring
  • Protection from diseases
  • Avoidance of teratogenic substances like alcohol and exposure to radiations

At delivery

  • Delivery should be conducted in the hospital
  • Apgar scoring has to be done at 1 and 5 minutes after the birth of a child
  • Close monitoring of mother and child

Childhood

  • Improved general medical care for children
  • Improved nutrition for children
  • Proper and early treatment for childhood infections
  • Immunisation of children according to immunisation schedule

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Substance Abuse

Substance Abuse

Substance Abuse

Substance abuse, as a disorder, refers to the abuse of illegal substances or the abusive use of legal substances. Alcohol is the most common legal drug of abuse.

SUBSTANCE ABUSE/CHEMICAL DEPENDENCE IN ADOLESCENTS

Alcohol and other drug use pose a serious threat to health of children and adolescents. In addition to health risks, substance abuse is often linked with other risk behaviors like violence, early sexual activity, truancy and academic failure.

 Pediatricians and other PHC providers are in ideal positions to identify substance abuse and to provide preventive guidance and education to children, adolescents and their families.

Epidemiology

Between 1990’s and recent, the prevalence rates of alcohol and other drug abuse among adolescents are increasing. Research has found out that one of every two adolescents has tried an illicit drug by the time he completes high school. The most commonly abused drug is alcohol.

Definitions

There are different terms used to define substance-related disorders, including the following:

Substance abuse; Substance abuse refers to an illegal use of a substance leading to significant problems or distress

Such as problems might include;

  • failure to attend school
  • substance use in dangerous situations (driving a car)
  • substance-related legal problems
  • interfering with friendships and/or family relationships
Tolerance; refers to a need for increased amounts of a substance to attain the desired effect.

Substance dependence

Substance dependence refers to a compulsive use and continuous relying on a specific substance for both physical and psychological relief with an inability to stop its usage even after significant problems in everyday functioning have developed.

Signs include;

  • an increased tolerance
  • Withdrawal symptoms with decreased use
  • unsuccessful efforts to decrease use
  • increased time spent in activities to obtain substances
  • withdrawal from social and recreational activities
  • continued use of a substance even with awareness of physical or psychological problems encountered by the extent of the substance use

Alcohol intoxication; this is a temporary mental disturbance following heavy drinking so that the level of alcohol in blood is high and sufficient to affect someone’s activity, mood and level of consciousness.

Alcoholism; is a chronic condition where a person takes alcohol excessively and for long period of time thus leading to adverse physical, mental, social and psychological effects

Alcoholic; is a person who have been taking alcohol excessively and for a long period of time in whom it has cause serious mental, social, psychological and physical problems

Substances commonly abused by adolescents

Substances frequently abused by adolescents include, but are not limited to, the following:

  • Alcohol
  • Marijuana
  • Tobacco
  • Prescription drugs 
  • Hallucinogens
  • Cocaine
  • Amphetamines
  • Opiates
  • Anabolic steroids
  • Inhalants
  • Methamphetamine

Causes of substance abuse

1.   Cultural and societal norms and acceptable standards of substance use. Public laws determine the legality of the use of substances.

2.  Genetic vulnerability; it tends to run in families

3.  Psychological problems such as;

  • -anxiety
  • -stress and frustrations
  • -feelings of desire

4.  Environmental stressors such as;

  • -failure of exams
  • -worry of the future
  • -failure to achieve a certain goal
  • -child abuse
  • -faulty upbringing
  • -lack of education
  • -large uncontrolled families
  • -economic constraints
  • -rape, incest and defilement

5.  Social pressures from peers

6.  Individual personality disorders

7.  Psychiatric problems such as;

  • -depressive disorder
  • -suicidal intentions
  • -paronea

Adolescents at risk of substance abuse

Parental and peer substance use are two of the more common factors contributing to youthful decisions regarding substance use.

Some adolescents are more at risk of developing substance-related disorders, including adolescents with one or more of the following conditions present:

  • Children of substance abusers
  • Adolescents who are victims of physical, sexual, or psychological abuse
  • Adolescents with mental health problems, especially depressed and suicidal teens
  • Physically disabled adolescents
  • Children whose parents deal with substances for financial support

Symptoms of substance abuse

The following behaviors may indicate an adolescent is having a problem with substance abuse. However, each adolescent may experience symptoms differently. Symptoms may include:

  • Getting high on drugs or getting intoxicated (drunk) on a regular basis
  • Lying, especially about if and how much they are using or drinking
  • Avoiding friends and family members
  • Giving up activities they used to enjoy such as sports or spending time with nonusing friends
  • Talking a lot about using drugs or alcohol
  • Believing they need to use or drink in order to have fun
  • Pressuring others to use or drink
  • Getting in trouble at school or with the law
  • Taking risks, such as sexual risks or driving under the influence of a substance
  • Suspension from school for a substance-related incident
  • Missing school due to substance use and/or declining grades 
  • Depressed, hopeless, or suicidal feelings

Diagnosis of substance abuse

A pediatrician, family doctor, psychiatrist, or qualified mental health professional usually diagnoses substance abuse in adolescents. However, adolescent substance abuse is believed by some to be the most commonly missed pediatric diagnosis. Adolescents who use drugs are most likely to visit a doctor’s office with no obvious physical findings. Substance abuse problems are more likely to be discovered by doctors when adolescents are injured in accidents occurring while under the influence, or when they are brought for medical services because of intentional efforts to hurt themselves.

  • History taking; this can reveal personal history on substance abuse
  • Clinical presentation; this often depend on the substance abused, the frequency of use, and the length of time since last used, and may include:
  • Weight loss
  • Constant fatigue
  • curly hair
  • Red eyes
  • Little concern for hygiene
  • use of the questionnaire of CAGE

Treatment for substance abuse

Specific treatment for substance abuse will be determined based on:

  •  Adolescent’s age, overall health, and medical history
  • Extent of  adolescent’s symptoms
  • Extent of  adolescent’s dependence
  • The substance abused
  •  Adolescent’s tolerance for specific medications or therapies
  • Expectations for the course of the condition
  •  Opinion or preference of the care taker

A variety of treatment programs for substance abuse are available on an inpatient or outpatient basis. Programs considered are usually based on the type of substance abused.

Medical detoxification (if needed, based on the substance abused) and long-term follow-up management are important features of successful treatment.

Long-term, follow-up management usually includes formalized group meetings and age-appropriate psychosocial support systems, as well as continued medical supervision. Individual and family psychotherapy are often recommended to address the developmental, psychosocial, and family issues that may have contributed to and resulted from the development of a substance abuse disorder.

Prevention of substance abuse

There are three major approaches used to prevent adolescent substance use and abuse, including the following:

  • School-based prevention programs. School-based prevention programs usually provide drug and alcohol education and interpersonal and behavior skills training.
  • Community-based prevention programs. Community-based prevention programs usually involve the media and are aimed for parents and community groups. Programs, such as Mothers Against Drunk Driving (MADD) and Students Against Drunk Driving (SADD), are the most well-known, community-based programs.
  • Family-focused prevention programs. Family-focused prevention programs involve parent training, family skills training, adolescent social skills training, and family self-help groups. Research literature available suggests that components of family-focused prevention programs have decreased the use of alcohol and drugs in adolescents and improved effectiveness of parenting skills.

ALCOHOL AND DRUG ADDICTION

Alcohol and drug addiction have been a source of serious problems for thousands of years. Recent studies indicate that there are more psychoactive, psychological and social problems related to alcoholism and drug addiction than anything else which affect the individual and society emotionally.

The following are the commonly abused groups of substances;

  • Alcohol
  • Cannabis
  • Cocaine
  • Nicotine
  • Opioids
  • Sedatives-hypnotics/anxiolytics

Terms

Drug (substance); this refers to any chemical agent that once taken in the body is capable of causing physiological and psychological changes.

Alcoholic; this is a person who has been taking alcohol excessively in whom it has produced mental, social, physical and psychological problems

Substance intoxication; this is development of a reversible substance-specific syndrome due to recent ingestion of or exposure to the drug

 Alcohol intoxication; a this is a temporally mental disturbance following heavy drinking so that the level of alcohol in blood is high and sufficient to affect somebody’s activity, mood and level of consciousness.

Tolerance; this is a need for more of the drug in order to achieve a similar effect realised before at a lower dose

Dependency; refers to compulsion to take the drug on a continuous basis in order to feel its effects and to further avoid the discomfort of its absence. This can both be physical or psychological. It is a bodily response to a substance e.g. relying on medications to control medical condition.

Addiction; this refers to a psychological and physical inability to stop consuming a drug or substance even though it’s causing psychological and physical harm. it involves using the drugs despite the consequences.

Misuse refers to the incorrect, excessive or non-therapeutic use of and mind-altering substances

ALCOHOLISM

Definition; alcoholism is a chronic condition occurring in individuals who have been taking alcohol excessively and for a long period of time that it has caused serious adverse effects physically, socially and mentally i.e. There is increased dependency of alcohol both physically and socially.

Causes of alcohol abuse

  • Availability; if alcohol is available and drinking is accepted for example as a norm in social gatherings and functions
  • Genetic factors; some excessive drinkers have a family history of excessive drinking
  • Poor coping strategies; people who are unable to face stress often resort to alcoholism
  • Psychiatric disorders; like depressive disorders, anxiety disorders an phobic disorders
  • Social disorders; like isolation, unemployment, loss or bereavement, injustice etc.
  • High risk groups e.g. people suffering from chronic physical illness, business executives, travelling salespersons, industrial workers, hostel students, military personnel etc.
  • Age; its common between late adolescence and early adulthood

Process of alcoholism

  1. Experimental; due to peer pressure, influences or curiosity, the person starts to consume alcohol
  2. Recreational; during weekends, or on holidays, the individual starts to enjoy and continue with it. If consumed in small quantities, alcohol may not cause a problem instead it may work to relieve tension and relax mind or sedate the brain from painful emotions and promote a sense of wellbeing and pleasure.
  3. Compulsive; once used to drinking, some people who started drinking occasionally start drinking almost daily or drinking heavily for a period of time for pleasure or to avoid the discomfort of withdrawal symptoms.

Alcoholism goes through distinct stages;

Early stage

Increased tolerance– needing more and more of alcohol to experience the same pleasure as experienced earlier

Blackouts- inability to recollect incidents which happened under the incidence of alcohol

Preoccupation– always thinking about how, when and where to drink

Middle stage

Loss of control over amount, time and occasional drinking, Keeping away from alcohol for sometimes but going back to obsessive drinking after some period

Chronic stage

Getting drunk even on small amounts of alcohol, willing to lie, beg, borrow or steal to maintain supply of alcohol. Alcohol takes the priority over family or job.

Types of drinkers

Mild drinkers

These rarely and occasionally drink alcohol in small amounts or in large amounts but once in a while and it rarely causes problems

Moderate drinkers

These moderately consume not in excess nor large amounts and it doesn’t cause much health problems

Problem drinkers

These consume large amounts of alcohol daily and usually with high concentrations. As a result, the individual health will be impaired, affects peace of mind, disrupts family, loss of reputation, dignity, poor performance etc.

Effects and complications of alcohol

Physical or medical effects
  • Hepatitis and liver cirrhosis
  • Pancreatitis
  • Peptic ulcers and gastritis
  • Cardiomyopathies and heart failure
  • Epileptic-like fits (RUM fits)
  • Tuberculosis
  • Weight loss
  • Alcoholic dementia
  • Anaemia
  • Malnutrition
  • Lowered immunity
Psychiatric effects
  • Depression
  • Pathological intoxication such as maladaptive behavioural effects such as fighting, impaired judgement, slurred speech, mood changes, irritability and impaired attention
  • Delirium tremens
  • Alcoholic hallucinosis which are vivid hallucinations developing shortly after cessation or reduction of alcohol
  • Alcoholic psychosis this occurs after a person drinking alcohol for a long periods of time and in large quantities and thus develops psychotic disorder which resemble paranoid schizophrenia presenting with delusions, hallucinations and impairment of primary mental functions.
  • Alcohol amnestic disorder; there is impairment in short and long term memory with disorientation and confabulation
  • Alcoholic dementia; a chronic organic mental disorder that results into irreversible impairment in memory, orientation etc.
  • Suicide
  • Anxiety
  • Paranoia- persecutory and feelings of self-hate
  • Morbid or pathological jealousy e.g. a drunkard coming back at home and finds a ranch of a bicycle and begins quarrelling who has been at home
  • Hallucinations
  • Wernicke’s encephalopathy that occurs as a result of acute deficiency of vitamin B1 (Thiamine) in alcoholics
  • Korsakoff syndrome that occurs as a result of gradual depletion of thiamine from the body.
Social problems
  • Decreased work performance hence decreased productivity due to chronic absenteeism
  • Family problems like divorce
  • Increased accidents due to drunken driving
  • Legal effects like rape, theft etc.
  • Violence and aggression

Diagnosis of alcoholism

  1. History taking i.e. upbringing, family background, period taken while bussing etc.
  2. Clinical presentation like curly hair, swollen cheeks, red lips, poor hygiene etc.
  3. Using the questionnaire of CAGE

C- Cut

  • Annoyed

G- Guilty

E- Eye opener

The questionnaire looks as below;

Have you ever felt that you should cut down your drinking?

  1. Yes
  2. No

Have people annoyed you by criticizing your drinking?

  1. Yes
  2. No

Have you ever felt guilty about your drinking?

  1. Yes
  2. No

Have you ever had a drink as a first thing in the morning as eye opener to get rid of hangover or calm your nerves?

  1. Yes
  2. No

Affirmative answers or any yes to two or more of the above is a suggestive to an alcoholic

Concentration of alcohol in blood with their effects

  • 80-150mg of alcohol per 100mls of blood leads to intoxication
  • 150-300mg of alcohol per 100mls of blood is fatal
  • 300-500mg of alcohol per 100mls of blood is very fatal
  • 500mg of alcohol per 100mls of blood and above leads to death

Note; all the above symptoms can change according to tolerance

Management of alcoholism

Aims

The following are the major goals in the management of alcoholism;

  • To detoxify the patient (only in acute stages)
  • To improve social relationships and support
  • Developing confidence and ability to change
  • Identifying reasons to change
  • Developing alternative activities
  • Learning to prevent relapse

Admission

Admission is very essential to ensure that the patient doesn’t have access to alcohol. The patient has to be hospitalised and not allowed home for about 6-8 weeks since they have tremendous for alcohol and can soon start drinking if allowed home.

  • Admit the patient in a psychiatric hospital in an open quiet room which is well lit to reduce fears and illusions
  • Establish a good nurse patient relationship
  • Keep potentially harmful objects away from the room since there is chance of deliberate self-harm
  • Keep the bed dry, clean and warm since the patient might be incontinent
  • Monitor vital signs every 15 minutes initially including physical and mental behaviour
  • Investigations such as
  • Urine for sugar
  • Blood for haemoglobin level and sugars
  • Alcohol level in blood have to be carried out

Medication

  • Administration of minor tranquilizers like anti-anxiety drugs such as Librium and diazepam are given parenterally if necessary to control anxiety, insomnia, agitation and tremors
  • Administer ant-convulsants if there is withdrawal seizure (rum fits)
  • Plenty of vitamins especially injection vitamin B1,B6 and B12 (100-300mg twice daily for seven days) and tablets of vitamin B complex and vitamin c
  • Antacids to relieve gastritis
  • Correct fluid and electrolyte imbalance by intravenous infusion and maintain a fluid balance chart
  • Drug Disulfiram (ant abuse therapy) which produces nausea and vomiting, intense headache, palpitation, blurred vision, hypotension and dyspnoea if alcohol is taken. It can be administered but under close patient supervision it is given 1g for one week then o.8g-0.6g-0.4g-0.2g and the patient is maintained on 0.1g for one year
  • Aversion therapy (Apo morphine) this is given in injectable form. It is a powerful emetic and the patient vomits whenever he smells alcohol. It is therefore discouraged for that
  • Yeast tablets are given two twice a day to induce appetite
  • Stamatil (avomine) is given 5-10mg to control vomiting
  • Sedation of the patient may be required
  • Avoid barbiturate drugs because alcoholics easily become addicted to them

General nursing care

  • Physical and psychological conditions or mental conditions associated with advanced alcoholism should be treated like malnutrition, vitamin deficiencies, hallucinations, delirium, gastritis or liver diseases
  • Nutrition; Ensure that the patient takes small frequent feeding rather than large meals and the diet should be nutritious and appetising to enable the patient ask for more
  • Hygiene; oral care, general body and bed hygiene has to be addressed
  • During the recovery and rehabilitation period, acceptance of the patient by the nurse is essential. The nurse’s acceptance and may encourage the patient to socialise and participate in planned activities. This will also reduce the patient’s feelings of inferiority and low self-esteem.
  • Psychiatric social workers should be involved in the social problems of the patient
  • Religious commitment has to be encouraged
  • Familial therapy; these should be encouraged to help the patient to stay away from alcohol
  • Patient should be encouraged to change friends and associates may be necessary to remove patient from those situations where drinking is very easy
  • Prepare the patient for alcoholic anonymous a self-group of ex-addicts who confront, instruct and support fellow drinkers in their efforts to stay sober one day at a time, through fellowships and acceptance.
  • Plan for discharge and resettlement of the patient into the community

                STEPS OF ALCOHOLIC ANONYMUS

  1. We admitted we were powerless over alcohol – that our lives had become unmanageable. AA firmly believes that individuals cannot overcome alcoholism on their own. They are unable to exercise willpower or personal strength that could prevent them from drinking
  2. Came to believe that a Power greater than ourselves could restore us to sanity. Alcoholics Anonymous is based on the belief in a higher power. For some, this higher power may be God; for others, it may be a belief in the universe itself. The point is that recovery begins, in part, by looking to an entity greater than yourself.
  3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
  4. Made a searching and fearless moral inventory of ourselves. During this step, many participants make a list of poor decisions or character flaws. They outline hurt they caused to others, as well as feelings, like fear and guilt, that motivated some of their past actions. Once the individual has acknowledged these issues, the issues are less likely to serve as triggers to future alcohol abuse.
  1. Admitted to God, to ourselves and to another human being the exact nature of our wrongs. As AA members work this step, they sit down with someone – often their sponsor – and confess everything they identified in Step 4. This step requires the recovering individual to put aside their ego and pride to acknowledge shameful past behavior. The step is also empowering, as the alcoholic no longer has to hide behind guilt and lies.
  1. Were entirely ready to have God remove all these defects of character. In this step, the recovering alcoholic acknowledges that he or she is ready to have a higher power – again, whatever that may be – take away the moral shortcomings identified in
  1. Humbly asked Him to remove our shortcomings. This step requires the person to focus on the positive aspects of his or her character – humility, kindness, compassion and a desire for change – as well as step away from the negative defects that have been identified.
  1. Made a list of all persons we had harmed, and became willing to make amends to them all. During this step, recovering alcoholics write down a list of all the people they have hurt. Often, this list includes people they hurt during their active alcoholism; however, it may go back further to include anyone they have hurt throughout their entire lives
  1. Made direct amends to such people wherever possible, except when to do so would injure them or others. Paired with Step 8, Step 9 gives recovering alcoholics the opportunity to make things right with those they have hurt. One’s sponsor can be a big source of help during this process, helping the recovering alcoholic to determine the best way to go about making amends.
  1. Continued to take personal inventory and when we were wrong promptly admitted it. Linked to Step 4, this step involves a commitment to continue to keep an eye out for any defects of character. It also involves a commitment to readily admit when one is wrong, reinforcing humility and honesty.
  1. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Step 11 commits the recovering alcoholic to continued spiritual progress. For some, this may mean reading scripture every morning. For others, it may mean a daily meditation practice. Alcoholics Anonymous doesn’t have stringent rules on what form spiritual growth takes. It simply involves a commitment to take time to reassess one’s spiritual and mental state.
  1. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs practice these principles in all our affairs. The final step involves helping others and serves as motivation for many to become sponsors themselves. By going through the 12 steps, individuals have a major internal shift and part of that shift is a desire to help others.

Nurses role in the prevention of alcohol abuse

Primary prevention

Aim to avoid the appearance of new cases of alcohol abuse by reducing alcohol consumption through health promotion especially health education

Secondary prevention

Attempt to detect cases early and to treat them before serious complications cause disability

Tertiary prevention

Aim to avoid further disabilities and to reintegrate individuals into the society who have been harmed by severe alcohol related problems

The nurse will be involved in all of these levels

Substance Abuse Read More »

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is an anxiety disorder characterized hyper-arousal, re-experiencing of images of the stressful events and avoidance of reminders.

>  It is a disorder that develops after a person sees, is involved in or hears
(experiences) of an extreme traumatic stressor.
>   Is a condition occurring when an individual experiences extreme rare stressful event, the person reacts with severe anxiety, feeling of numbing and avoidance of thinking about the events which is often interrupted at times by sudden vivid and distressing recall of these events.
>  It is a mental health disorder associated with torture.

PTSD may be immediate response to the stressor or may follow an interval of days or occasionally months. It usually improves within months, but may persist for years.
Post Traumatic Stress Disorder was first recognized in 1980 by American Psychiatric Association (APA). Before, it was known as:-

  •  Shell shock
  • Soldiers’ heart
  • Rape trauma syndrome
  • Concentration camp syndrome.

Aetiology

1.  An exceptionally stressful event in which the person was involved in directly or as a witness.
Examples of stressful events.

  •  Wars
  • Floods
  • Earthquakes
  • Gang rape
  • Terrorism
  • Accidents
  • Fire out break

2.  However there is a variation in responses depending on personal vulnerability.
3.  Genes was found to be part of the vulnerability by twin studies.
4. Other predisposing factors. For example:

  •  Uncontrolled temperament.
  • Age: children and old people are more vulnerable.
  • Gender: women are more vulnerable
  • History of psychiatric disorders
  • Previous traumatic experiences including separation from the parents and child abuse.
  • Differences in a way threatening events are appraised and encoded in the brain.

5.  Neuroendocrine factors which include: sensitization of noradrenergic system.
Sensitization of serotonergic system. Reduction in cortisol levels.
6. Psychological factors:

  •  Fear conditioning. Classical conditioning may be involved.
  •  Cognitive theory: PTSD arises when the normal processing of emotionally charged information is over whelmed, so that memories persist in an unprocessed form in which they can intrude into the conscious awareness.
  •  Psychodynamic theory: emphasizes the role of the previous experience in determining the individual variations in response to severely stressful events.

7. Maintaining factors:

  •   Negative appraisal of early symptoms
  •  Avoidance of reminders which prevents deconditioning and cognitive reappraisal.
  •  Suppression of anxious thoughts.

Diagnostic criteria signs/ symptoms

1. The child has been exposed to a very traumatic event outside the usual range of human experience and would be frightening to any one.

  •  Could be the subject of trauma
  • Could be the perpetrator of the trauma.
  • Could be a mere observer.

2. Persistent re-experiencing of traumatic event.

  •  Recurrent and intrusive recollections of the events. (In young children, repetitive play may occur in which themes or aspects of trauma are expressed).
  • Recurrent distressing dreams of events. (A child may have frightening dreams without recognizable content).
  • Acting or feeling as if the traumatic event were recurring. (Trauma specific re-enactment may occur)
  • Experience intense psychological distress at exposure to events that symbolize or resemble the traumatic event).

3. Persistent avoidance of stimuli associated with trauma

  •  Efforts to avoid thought or feeling associated with trauma.
  • Avoiding activities or situations resembling the trauma.
  • In ability to recall important aspects of trauma.
  • Diminished interest in activities.
  • Feeling of detachment from others.
  • Restricted range of affect.
  • Sense of foreshortened future.

4. Persistent symptoms of increased arousal

  •  Difficult in falling or staying asleep.
  • Irritability or out burst of anger.
  • Difficulty in concentrating.
  • Hyper-vigilance – not settled.
  • Exaggerated startle response.
  • Physiological reactivity upon exposure to events symbolizes or resembles the trauma.

5. Symptoms for at least one month.
If symptoms last for:-

  •  Less than 3 months – acute PTSD
  • More than 3 months – chronic PTSD
  • Begin 6 months after the stressor- delayed PTSD.

Summary of symptoms of PTSD

The principle symptoms of post traumatic stress disorder includes;
Hyper-arousal

  •  Persistent anxiety
  •  Irritability
  •  Insomnia
  •  Poor concentration.

Intrusions

  •  Difficulty in recalling stressful events at will.
  •  Intense intrusive imagery (flash back).
  • Recurrent distressing dreams.

Avoidance

  •  Avoidance of reminders of the vents
  • Detachment
  • Inability to feel emotion (numbness).
  • Diminished interest in activity.

Reactions

  •  Night mares
  • Terrifying dreams
  • Vivid recall of the events (images)
  • Depression/ sadness
  • Irritable
  • Anxiety
  • Anti-social behaviors.

Management of PTSD

Treatment usually involves psychotherapy and counseling, medication, or a combination.

Assessment
Assess the following;

  •  Nature and severity of the stressful event
  • The nature and duration of the symptoms
  • Previous psychiatric history
  • Previous personality
  • Neurological examination should be done to exclude a subdural haematoma or other forms of cerebral injury. If the event included injury like from assault or accident.

Treatment
1. Early treatment

  •  If the response is not severe, sympathetic support and help with practical problems subsequent to disaster may suffice.
  • Counseling provides emotional support and discourages recall.
  • Facilitates working through the associated emotions.
  • Few doses of anxiolytic drugs may be needed to calm the person.
  • The person is helped to talk about and reconsider the event and express feelings about them. This may need to be done repeatedly.

2. Chronic PTSD is difficult to treat.

  •  It requires series of interview where by the person is encouraged to recall, re-experience and work through the emotions associated with the event.
  • Cognitive therapy or techniques have been used to desensitize patients to reminders and images of the stressful events.

Options for psychotherapy will be specially tailored for managing trauma.

3. Cognitive processing therapy (CPT): Also known as cognitive restructuring, the patient is taught to think about things in a new way. Mental imagery of the traumatic event may help them work through the trauma, to gain control of the fear and distress.

4. Exposure therapy: Talking repeatedly about the event or confronting the cause of the fear in a safe and controlled environment may help the person feel they have more control over their thoughts and feelings.

5. Medications

Some medications can be used to treat the symptoms of PTSD.

  • Selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, are commonly used. SSRIs also help treat depression, anxiety and sleep problems, symptoms that are often linked to PTSD. 
  • benzodiazepines may be used to treat irritability, insomnia, and anxiety. However, the National Center for PTSD do not recommend these, because they do not treat the core symptoms and they can lead to dependency.
  •  anxiolytics should be avoided unless other wise because of dependence after prolonged use. Antidepressants may be used in low doses for example fluoxetine could be given.

The patient has to be taught about the following self help techniques

Active coping is a key part of recovery. It enables a person to accept the impact of the event they have experienced, and take action to improve their situation.

  • learning about PTSD and understanding that an ongoing response is normal and that recovery takes time
  • accepting that healing does not necessarily mean forgetting, but gradually feeling less bothered by the symptoms and having confidence in the ability to cope with the bad memories

Other things that can help include:                          

  • finding someone to confide in
  • spending time with other people who know what happened
  • letting people know what might trigger symptoms
  • breaking down tasks into smaller parts, to make them easier to prioritize and complete
  • doing some physical exercise, such as swimming, walking ETC.
  • practicing relaxation, breathing, or meditation techniques
  • listening to quiet music or spending time in nature
  • understanding that it will take time for symptoms to go away
  • accepting that PTSD is not a sign of weakness but can happen to anyone
  • participating in enjoyable activities that can provide distraction

Post-traumatic stress disorder (PTSD) Read More »

antipsychotics

ATYPICAL ANTIPSYCHOTIC

Atypical or second generation or novel 

Atypical or ‘2nd generation’. These medications have been used since the 1990s. These are newer types of antipsychotics.

  • These are sometimes referred to as ‘atypicals’

These are newer antipsychotic drugs on the Ugandan market and are less commonly used because they are  expensive. They are however the best antipsychotics because they control both negative and positive  symptoms of schizophrenia. These drugs are also associated with fewer side effects compared to the  typical antipsychotics. Are also called new antipsychotic drugs.

  • Some are also less likely to cause sexual side effects compared to first generation antipsychotics.

But second generation antipsychotics may be more likely to cause serious metabolic side effects. This may include rapid weight gain and changes to blood sugar levels, diabetes mellitus, hypercholesterolemia.

Mechanism of Action 

  • They block 5-HT2A-receptors with lesser degree of antagonism of D2-receptor. 
  •  Have efficacy against negative effects especially clozapine 
  •  As a result, they have fewer extrapyramidal adverse effects than the older traditional agents.
  • Atypical agents are serotonin-dopamine 2 antagonists (SDAS)
  • They are considered atypical in the way they affect dopamine and serotonin neurotransmission in the four key dopamine path way in the brain.

Classes of Atypical Antipsychotics

  •  Benzoxazoles- Risperidone 
  • Dibenzodiazepines – Clozapine  
  •  Thienobenzodiazepine- Olanzapine  
  •  Dibenzothiazepine- Quetiapine   
  •  Imidazolidinone – Sertindole 

Risperidone (Risperdal)

  • Available in regular tabs, I.M depot form and rapidly dissolving tablet.
  • Functions more like atypical antipsychotic at doses greater than 6 mg.
  • Increased extra pyramidal side effects (dose dependent) 
  • Most likely atypical to induce hyperprolactinemia. 
  • Weight gain and sedation (dose dependent) 
  • Hypotension, fatigue, abdominal pain, nausea.

Olanzapine (Zyprexa)

  • Available in regular tabs, immediate release I.M, rapidly dissolving tab, depot form. Dose 5mg-20mg/ day-OD /nocte.

Side effects

  • Sedation, weight gain, hypotension, anti cholinergic effects, changes in liver function tests.

Quetiapine (Seroquel)

  • Available in a regular tablet form only.
  • Dose: 100-400mg bid or DDD

Side effects

  • Weight gain,
  • Most likely to cause orthostatic hypotension 
  • Increase blood sugar-diabetes     

Clozapine (Clozaril) 

Available in one form-a regular tablet

  • Dose: 100-900mg bid or in  DDD

Side effects

  • Sedation , weight gain 
  • Hyper salivation

SIDE EFFECTS OF ANTI-PSYCHOTICS:

Extra pyramidal side effects:

Most of the anti-psychotic drugs may cause the imbalance of the neurotransmitters (excitatory and inhibitory) resulting into side effects known as extra pyramidal.

  1. Acute dystonia– uncontrolled muscular spasm. Muscle from spasm many part of the body, for example:
  • Oculogyric: crisis-eyes rolling upwards. 
  • Torticollis: head and neck twisted to the side

The patient may be unable to swallow or speak clearly. in extreme cases , the back may arch or the jaw dislocate.

Management: 

  • Give artane tablets or anticholinergic drugs given orally, I.M or I.V depending on the severity of symptoms.
  • Benzodiazepines like diazepam.
  • Some times change in medication, or lowering dose.
  1. Parkinsonian symptoms (pseudo-parkinsonism)
  • Tremor
  • Rigidity 
  • Bradykinesia: decreased facial expression, flat monotone voice, slow body movements, inability to initiate movement.
  • Mask like face
  • Bradyphrenia
  • Slowed thinking 
  • Salivation
  • Drooping posture.

Management 

  • Reduce the antipsychotic dose.
  • Change to atypical drug (as antipsychotic monotherapy)
  • Prescribe an anticholinergic like Artane.
  1. Akathisia (restlessness);  A subjectively unpleasant state of inner restlessness where there is a strong desire or compulsion to move.
  • Foot stamping when seated.
  • Constantly crossing or uncrossing legs.
  • Rocking from foot to foot.
  • Constantly pacing up and down.

Management

  • Reduce or lower the antipsychotic dose.
  • Give benzodiazepines like diazepam
  • Give beta blockers like propranolol 
  • Give an anti cholinergic like artane.
  1. Tardive dyskinesia (abnormal movement): It is an irreversible extrapyramidal syndrome usually common in patients who have been on anti-psychotics for long. It is characterized by persistent involuntary movement of all oral facial muscles.
  • Rabbit syndrome: lip smacking or chewing type movement as of a rabbit.
  • Tongue protrusion: fly catching.
  • Choreiform hand movements (pill rolling or piano playing)

Severe orofacial movement can lead to difficulty, speaking, eating, or breathing. Movements are worse when under stress.

Management:

  • Stop anti-cholinergic if prescribed
  • Reduce dose of anti psychotic.
  • Change to a typical drug.
  1. Neuroleptic malignant syndrome: It is rare but fatal (life threatening), occurs as a result of prolonged intake of anti psychotic drugs it is characterized by:
  • Severe mental, motor and autonomic disturbance.
  • Hyper tonicity increased muscle tone. There is an increased reflex to stimuli.
  • Generalized stiffness of the muscles affecting i.e. patient may find it unable to swallow.
  • Hyperpyrexia increased body temperature, because of that, they get profuse  sweating, this leads to fast dehydration
  •  There is increased blood pressure leading to tachycardia.

The mortality rate is 20 % as per global population. They need intensive medical and nursing.

For the above extra-pyramidal side effects, we use the following drugs to counter act them.

  • Benzhexol (artane)

We can use 2mg-4mg o.d /bid 4-5 days and then go back to PRN when acute. But otherwise, they are supposed to be given when necessary. It is under the group of anti-cholinergic drugs under the classification of drugs.

  • Benztropine mosylate (congetin)

It also falls under the group of anti-cholinergic.

Dose: 0.5-1mg to 4mg maximum o.d / PRN (orally) 

Injection: 1mg-2mg to I.m-PRN.

N.B: Children below 5yrs should not be given chlorpromazine (Largactil). Use haloperidol.

Other side effects as per systems.

Gastro intestinal tract(GIT)

  •  Dry mouth: Management: Rinsing of mouth with water (avoid candy ‘’sweetie’’ as carriers may result).
  •  Excessive salvation (sialorrhea): management give antiparkinsonian like artane or stop drug.
  •  Constipation: management: give high fibred diet, laxatives like bisacodyl
  •  Sedation: management: give smaller dose in the morning some patients can only cope with single night-time dosing. Reduce dose if necessary. 

Cardio vascular system:

  •  Postural hypotension (orthostatic hypotension): Management: advise patient to take time when standing up or change posture gradually. Reduce dose or slow down rate of increase 
  •  Cardiac arrhythmias (ECG changes): Management:  ECG monitoring, change drug.

Endocrine and metabolic system:

  •  Weight gain: Management: dietary control, exercise, change drug.
  • Galactorrhea (increased lactation): Management: change the drug
  • Amenorrhea: Management: change the drug.
  • Decreased libido: Management: reduce dose or change drug.

Haemotological.

  • Bone marrow depression.
  • Obstructive jaundice.

Ocular 

  • Blurred vision 
  • Glaucoma- increased intraocular pressure
  • Retina  pigmentation (may lead to blindness)

Genital and urinary systems.

  • Retention of urine-people can retain or pass urine 
  • Polyuria- excessive passage of urine of low specific gravity.
  • Impotence.

Allergic.

  • Photo sensitivity.
  • Skin pigmentation.
  •  Nasal congestion (thioridazine)

NURSE’S RESPONSIBILITY FOR A PATIENT RECEIVING ANTIPSYCHOTICS

  • Instruct patients the patient to take sips of water frequently to relieve dryness of mouth. Frequent mouth washes, use of chewing gum, applying glycerine on the lips are also helpful.
  • A higher fiber diet, increased fluid intake and laxatives if needed, help to reduce constipation.
  • Advise the patient to get up from the bed or chair slowly. Patient should sit on the edge of the bed for one full minute dangling his feet before standing up. Check BP before and after medication is given. This is an important measure to measure to prevent falls and other complications resulting from orthostatic hypotension.
  • Differentiate between akathisia and agitation and inform the physician. A change of drug may be necessary if side effects are severe. Administer antiparkinsonian drugs as prescribed
  • Observe the patient regularly for abnormal movements
  • Take all seizure precautions.
  • Patient should be warned about driving a car or operating machinery when first treated with antipsychotics. Giving the entire dose at bedtime usually eliminates any problem from sedation.
  • Advise the patient to use sunscreen measures (use of full sleeves, dark glasses etc) for photosensitive reactions.
  • Teach the importance of drug compliance, side-effects of drugs and reporting if too severe, and regular follow ups. Give reassurance and reduce unfounded fears and anxieties.
  • Seizure precautions should also be taken as clozapine reduces seizure threshold. The dose should be regulated carefully and the patient may also be put on anticonvulsants such as carbamazepine.

Typical Antipsychotics

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ATYPICAL ANTIPSYCHOTIC Read More »

antipsychotics

Classifications of Antipsychotics.

Classification of Antipsychotics

  1. Typical (first generation)(conventional) antipsychotics.
  2. Atypical (second generation) antipsychotics.

Typical Antipsychotics or first-generation (conventional)

  • Also called typical, conventional or traditional antipsychotic agents
  • Their antipsychotic effects reflect competitive blocking of D2 receptors
  • More likely to be associated with extra pyramidal side effects (EPS) or movement disorders, such as Parkinsonism,  neck stiffness, protrusion of the tongue, upward eyeball rolling.  
  • This is most common with the highly potent drugs.
  • Primarily improve positive symptoms of schizophrenia
  • Low potency typical antipsychotics have less affinity for the D2 receptors but  tend to interact with non dopaminergic receptors resulting in more cardio toxic and anti-cholinergic adverse effects including sedation, hypotension. 

These are the most commonly used drugs in Uganda because they are cheap and available. Typical  antipsychotics are more effective in the treatment of positive symptoms than the negative symptoms.

Mechanism of Action

Predominantly block dopamine D2 receptors in the mesolimbic system of the brain.   Also blocks:  

  •  Muscarinic acetylcholine receptors  
  •  Histamine H1 receptors  
  •  Αlpha adrenoreceptors  

 The binding affinity of the typical is very strongly correlated with clinical antipsychotic and  extrapyramidal potency: the typical antipsychotic drugs must be given in sufficient doses to  achieve 60% occupancy of striatal D2 receptors 

Classes of Typical Antipsychotics

  1. Phenothiazines.
  2.  Butyrophenones.
  3. Thioxanthones.

Phenothiazines

  • Chlorpromazine (Thorazine)(Largactil)
  • Fluphenazine (Prolixin) 
  • Perphenazine (Trilafon)
  • Prochlorperazine (Compazine)
  • Thioridazine (Mellaril)
  • Trifluoperazine (Stelazine)
  • Mesoridazine
  • Promazine
  • Triflupromazine (Vesprin)
  • Levomepromazine (Nozinan)
  • Promethazine (Phenergan)

Chlorpromazine (Largactil)

 Chlorpromazine it is in a phenothiazine group. It has high sedating properties but with low extra pyramidal side effects. It is absorbed in the jejunum (in alimentary canal) and metabolized in the liver. Anti- depressants reduces metabolism of chlorpromazine. Chlorpromazine works as a competitor for relevant enzymes.

Indications

  • Schizophrenia (psychotic disorders).
  • Mania.
  • Agitation in the elders.
  • Alcohol related problems (where there are no antipsychotic drugs i.e. haloperidol and thioridazine).
  • Intractable hiccups. 
  • Nausea and  vomiting
  • It can also control spasms in small doses i.e. in tetanus.

Contra-indications:

  • Liver diseases e.g. liver cirrhosis, bone marrow depletion, in glaucoma (increased pressure in the eye.)

N.B: Chlorpromazine can induce seizures it lowers the threshold of a seizure, so a fit chart should be put to observe that.

Dosage

Orally: Depending on the severity of psychosis, dosages can range from 100mg-1500mg in daily divided doses (DDD) as per prescription. 

Injectables: This may range from 25-200mg IM. This may be given start depending on the severity of the condition. Or: It may be given continuous i.e. (continuous narcosis) i.e. 8 hourly or 12hourly, until the patient calms down, then oral treatment can be continued with.

Rectal suppository : Each suppository is of 100mg, this may be OD, BD, or TDS. It may be used in children above 5 years who cannot take drugs orally.

Syrups: This is 25mg/5mls. Suspension is also 100mg/5mls

Note: haloperidol and stelazine may be preferable in epileptic patients.  

 Piperazine e.g. Trifluoperazine (stelazine)

It is a neuroleptic of phenothiazine group. It has high extra pyramidal side effects and less sedating effects. It also has high properties of anti-hallucigenesis.

Indications:

  • Schizophrenia
  •  Mania  
  • Organic brain syndrome 
  • Mental  retardation with psychosis
  • Agitation in the elderly.
  • Severe anxiety.

Note: It’s a good drug in schizophrenic patients with negative features such as apathy, social with draw, lack of self drive.

Dosages

Oral tablets: 5-45mg in divided doses (DDD)

Injectable: 1-3mg IM. the maximum is usually 6mg, this may be given PRN.

 Piperidine e.g. Thioridazine (melleril)

It is a neuroleptics in phenothiazine group. It has moderate sedating effects and less extra pyramidal side effects, but with high anti-cholinergic effects. 

Indications:

  • Schizophrenia. 
  • Mania.
  • Agitation in the elderly (moderate side effects)

N.B: Their regular blood pressure should be monitored.

  • Behavioral disorders associated with psychosis 
  • Severe anxiety (it has also anxiolytic effect)

Contra-indications

  • As for chlorpromazine.

Dosage:

  • Give 100-1000mg in divided doses (DDD) depending on the severity of the condition.
  • Can also be given 1mg/kg body weight in children 

Butyrophenones

  • Haloperidol (Haldol) 
  • Pimozide (Orap)
  • Melperone
  • Benperidol
  • Triperidol

Haloperidol (haldol).

Generally, it has high extra pyramidal side effects but less sedating effects, 

Indications

  • Mania (drug of choice)
  • Schizophrenia
  • Alcohol related problems.
  • Organic brain syndrome of any cause 
  • Mental retardation with psychosis and agitation.
  • Nausea & vomiting 
  • Hiccup

Contra indications:

  • As for chlorpromazine.

Dosage: 5-30mg is divided doses; the maximum dose can be 60mg DDD.

It is in tablets form: 0.1, 0.5, 1mg,   5mg, and 10mg 

Injectables: 5mg-20mg IM start or continued narcosis i.e. 2hrly, 6hrly and 8hrly. 

Dosage range for children: 25-50microgram.

Trifluperidol (triperidol)

Dose: 6-8mg OD/BD or TDS

Benperidol

It is very good in patients with deviant behavior (anti-social personality disorders) 

Dose: 0.25-1.5mg OD, BD or TDS.

BLACKBOX WARNING
WARNING
See full prescribing information for complete Boxed Warning.
Increased Mortality in Elderly Patients with Dementia-Related Psychosis:
  • Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotics drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Haloperidol is not approved for the treatment of patients with dementia-related psychosis (see WARNINGS).

Thioxanthones.

  • Chlorprothixene
  • Flupentixol (Depixol and Fluanxol)
  • Thiothixene (Navane)
  • Zuclopenthixol (Clopixol and Acuphase)

Thioxanthines are psychotropic drugs in the neuroleptics group. They were the first neuroleptics to come into use.

They are noted to have very gross side effects. With production of  new  neuroleptics drugs, the use of thioxanthines has reduced.

Indications: 

  • Schizophrenia (chronic)
  • Mania
  • And other psychotic associated conditions.

Flupentixol (depixal)

Dose: 3mg-9mg. The maximum dose can be 18mg in divided doses 

N.B: avoid giving neuroleptic injectables by I.V route for the fear of postural hypotension.

ANTIPSYCHOTIC DEPOT INJECTIONS (LONG ACTING) 

These are antipsychotics given by injection I.M. They are oily in nature and therefore, slowly released and metabolized over a period of 2 weeks up to 4 weeks.

Indications 

  • Chronic schizophrenia 
  • Cases of persistent mania 
  • Where there is total lack of oral medication compliancy in a psychotic patient. 
  • When it can be consistently be maintained. 

Give it concurrently with other oral treatment. However, it can be given alone as a maintained treatment.

Haloperidol decanoate (haldol decamate).

Dose: 50mg, 100mg-150mg (maximum) I.M. This is given monthly (4weeks).

Fluphenazine decanoate (modecate)

Initially with 12.5mg I.M stat if he is starting then 25mg-50mg for 2-4weeks

Fluspirilence (redeptin) 2mg/ml.

Give 2-4mg which is equivalent to 2mls. We can give 2mg in alternative days or weekly for one month (½) or 2months

Flupentixol decanoate (depixol)

It is very useful in patients with negative feature of schizophrenia. It has mood elevating effects.

Dose: Initially 20mg I.M, then after 10 days, increased to 40mg I.M 2-4 weekly.

Note:

  1. Give a quarter or half stated doses in elderly.
  2. After test dose, wait 4-10days before starting titration to maintenance therapy 
  3. Dose range is given in mg/week for convenience only avoid using shorter dose intervals than those recommended except in exceptional circumstances e.g. long  interval necessitates high volume ( >3-4ml) injection. 

Advice on prescribing depot injection/ medication:

  • Give a test dose.
  • Begin with the lowest therapeutic dose.
  • Administer at the longest possible licensed interval 
  • Adjust doses only after an adequate period of assessment

ATYPICAL ANTIPSYCHOTIC

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antipsychotics

Antipsychotics

Antipsychotics

Antipsychotics are a type of psychiatric medication which are available on prescription to treat psychosis.

 Anti psychotic drugs are psychiatric drugs used in treatment of mental disorders that are  characterized by disturbance of reality and perception, impaired cognitive functioning, and diminished  mood 

They are licensed to treat certain types of mental health problem whose symptoms include psychotic experiences.

Antipsychotics, also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis, mainly schizophrenia but also in a range of other psychotic disorders such as manic states with psychotic symptoms

They are also used together with mood stabilizers in the treatment of bipolar disorder, and they are also used in  management of other psychosis associated with depression and manic depressive illness and psychosis  associated with Alzheimer’s disease. 

Introduction to Psychosis

The term psychosis refers to a variety of mental disorders characterized by one or more of the following  symptoms:  

  1.  Diminished and distorted capacity to process information and draw logical conclusions  
  2.  Hallucinations, usually auditory or visual, but sometimes tactile or olfactory 
  3.  Delusions (false believes)  
  4.  Incoherence or marked loosening of associations  
  5.  Catatonic or disorganized behavior  
  6.  Aggression or violence 

 Antipsychotic drugs lessen these symptoms regardless of the underlying cause or causes ;

 Conditions characterized with psychosis include

  • schizophrenia,
  • mania,
  • bipolar disorder,
  • schizoaffective disorder,
  • depression,
  • alcohol withdraw syndrome,
  • and delirium. 

Factors that may lead to psychosis. 

  1.  Genetic factors 
  2.  Alcoholism 
  3.  Brain tumor 
  4.  Brain injures 
  5.  Central nervous system stimulants eg cocaine.  

Psychosis-Producing Drugs 

  1.  Levodopa 
  2.  CNS stimulants like 
  •  Cocaine  
  •  Amphetamines 
  •  Khat, cathinone, methcathinone  

     3.  Apomorphine ,Phencyclidine

Neurotransmitters 

  1. Excitatory: dopamine, adrenaline, nor adrenaline, serotonin (5-HT-5-hydroxy tryptamine)
  2. Inhibitory: Gama Amino Butyric acid (GABA)

 SCHIZOPHRENIA 

 Schizophrenia is a chronic mental disorder (psychotic) characterized by disordered thinking and loss of  touch with reality.

In other words, it is a mental disorder characterized by;

  • change in personality leading to  inability to relate to others ,
  • disturbed mood ,
  • impaired appreciation and interpretation of environment

The onset of symptoms usually occurs during adolescence and early adulthood.

Schizophrenia is thought  to be caused by excessive release of dopamine which leads to over stimulation of the brain cells resulting  into abnormal behavior. 

DOPAMINE 

  • it’s a neurotransmitter found in brain  

Effects of Dopamine 

  • Dopamine (DA) plays a critical role in initiation of movement.  
  • Controls reinforcement and cognitive function.  
  • Regulates prolactin release  
  • Plays a major role in vomiting  
  • Regulates temperature  
  • Reduces appetite  

Signs and symptoms 

Symptoms of schizophrenia are classified into two namely positive symptoms (due to distorted function)  and negative symptoms (due to diminished function).  

Positive and negative symptoms of schizophrenia 

Positive symptoms 

Negative symptoms

Hallucinations( Hearing voices, seeing things) 

Social withdrawal

Delusions( False belief) 

Emotional withdrawal

Disorganized speech 

Lack of motivation

Agitations 

Poverty of speech

 

Flat mood

 

Poor self – care

  • The positive symptons are due to stimulation. If you want to reduce these effects you would use a  depressant drug which would worsen the negative symptoms. 
  • The negative symptoms are due to depression. If you want to treat them, we would use a  stimulant drug which would potentiate the positive symptoms.  
  • The clinical phenotype varies greatly, particularly with respect to the balance between negative  and positive symptoms  
  • The positive symptoms are associated with increase in Dopamine pathway activation whereas the  negative symptoms are associated with a decrease in serotonin pathway activation.  
Key path ways affected by dopamine in the brain antipsychotics

Key path ways affected by dopamine in the Brain.

  1. Meso-cortical: – projects from the brain stem to the cerebral cortex. This path way is felt to be where the negative symptoms and cognitive disorders (lack of executive function) arise. Problem here for a psychotic patient, is too little dopamine. 
  2. Meso-limbic: – projects from the dopaminergic cell bodies in the ventral tegmentum (brain stem) to the limbic system. This pathway is where the positive symptoms come from (hallucinations, delusions and thought disorders). Problem here in a psychotic patient, there is too much dopamine.  
  3. Nigro striatal: – projects from dopaminergic cell bodies in the substantia nigra to the basal ganglia. This pathway is involved in movement regulation. Remember that dopamine suppresses acetylcholine activity. Dopamine hypo activity: can cause parkinsonian movements i.e. rigidity, brady kinesia, tremors, akathisia and dystonia
  4. Tuberoinfundibular: projects from the hypothalamus to the anterior pituitary. Remember that the dopamine release inhibits or regulates prolactin release. Blocking dopamine in this way will predispose your patient to hyper prolactinemia (gynecomastia/galactorrhea/decreased libido/ menstrual dysfunction).

General mechanisms of action antipsychotics

  • Blocking the action of dopamine receptors and path ways. Some scientists believe that some psychotic experiences are caused by the brain producing too much of a chemical called dopamine.  Dopamine is a neurotransmitter, which passes messages around the brain. Most antipsychotic drugs are known to block some of the dopamine receptors in the brain. 
  • This reduces the flow of these messages, which can help to reduce  psychotic symptoms. By blocking these pathways antipsychotics can produce both therapeutic and adverse effects.

 Blockade of dopamine and /or 5HT2 receptors in mesolimbic system.  

Blockade of 5HT2 receptor (like the α2 receptors in ANS), which allows constant release of  serotonin.  

 Many of these agents also block cholinergic, adrenergic, and histaminergic receptors. The  undesirable side effects of these agents are often a result of actions at these other receptors 

Absorption and Distribution 

  • Most antipsychotics are readily but incompletely absorbed. 
  • Significant first-pass metabolism. 
  • Bioavailability is 25-65%. 
  • Most are highly lipid soluble. 
  • Most are highly protein bound (92-98%). 
  • High volumes of distribution (>7 L/Kg). 
  • Slow elimination. 

**Duration of action longer than expected, metabolites are present and relapse occurs, weeks after  discontinuation of drug.** 

Metabolism 

  • Most antipsychotics are almost completely metabolized. 
  • Most have active metabolites, although not important in therapeutic effect, with one exception.  The metabolite of thioridazine, mesoridazine, is more potent than the parent compound and  accounts for most of the therapeutic effect. 

Excretion 

• Antipsychotics are almost completely metabolized and thus, very little is eliminated unchanged. Elimination half-life is 10-24 hrs.

Groups, Types or Classifications of Antipsychotics. 

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Bipolar Affective Disorder

Bipolar Affective Disorder

Bipolar Affective Disorder

Bipolar Affective Disorder is formerly called manic-depressive illness (MDI). B.A.D is severe and persistent condition that causes serious lifelong struggle and challenge.

Bipolar affective disorder is a mental health condition characterized by mood swings, from deep and prolonged low mood (profound depression) to extreme euphoria (mania), with intervening normal periods.

Episodes of mood swings may occur rarely or multiple times a year. While some people will experience some emotional symptoms between episodes, some may not experience any.

They are of three kinds i.e.

  • Mixed bipolar disorder that is both manic and depressive episodes intermixed
  • Manic bipolar disorder; here there is predominant elation of mood, irritability, excessive motor activity and evident psychotic features
  • Depressed bipolar disorder; symptoms are characteristic of major depression with a history of at least one manic episode.

Symptoms of bipolar affective disorder

Symptoms of bipolar vary from person to person and from time to time depending on the phase the patient is in.

Manic episode

Manic episodes have at least 1 week of profound mood disturbance characterized by elation and irritability at least 3 of the following;

  • grandiosity
  • Increased energy, activity (boundless energy)
  • Exaggerated sense of well-being and self-confidence (euphoria)
  • Decreased need for sleep
  • Unusual talkativeness
  • Racing thoughts or flight of ideas
  • Distractibility
  • Poor decision making for example taking sexual risks or making foolish investments
Hypomanic episode

This is characterized by elated or irritable mood of at least 4 consecutive days duration. The diagnosis of hypomania requires at least 3 of the above symptoms the difference being that here the symptoms are not severe enough to cause marked impairment in social or occupational functioning

Depressive episode

In a major depressive episode, for the same 2 weeks a person may experience 5 or more of these symptoms with at least one of the symptoms being either depressed mood or loss of pleasure or interest.

  • Depressed mood, such as feeling sad, hopeless, tearfulness and irritability in children and teens
  • Marked loss of interest or feeling of no pleasure in almost all activities
  • Significant weight loss when not dieting
  • Psychomotor retardation or agitation
  • Either insomnia or sleeping too much (hypersomnia)
  • Either restlessness or slowed behaviour
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Decreased activity to think or concentrate
  • Thinking about, planning or attempting suicide
  • Melancholia; this refers to depression not triggered by a stressor

Management of bipolar affective disorder

The treatment of bipolar affective disorder is directly related to the phase of episode (i.e. depression or mania and the severity of that phase.

MANIA

Mania is condition characterized by excessive or extreme elation of mood and increased activity.

It is a state of mind manifesting with cheerfulness, euphoria, and rapidly changes to irritability.

Types of mania

Hypomania: This is a mild form of mania

Acute mania: Acute, severe and heavy form of mania

Delirious mania: Excitation characterized by confusion mainly found in organic psychoses.

Chronic mania: Mania that has occurred in the patient, it could be simple form but has failed to respond to various forms of treatment. It usually occurs in people 40 years and above.

CAUSES OF MANIA
  1. Genetic factors; mania is said to run in families
  2. Increase in levels of noradrenaline metabolites
  3. Imbalances in serotonin levels in blood
  4. Increase in dopamine levels
  5. Cyclothymic type of personality (mood swings) plays a big role in the causation of manic illness occurrence.
  6. Body physic;
  7. Psychosocial factors like those resulting from stresses e.g. Divorce, bereavement etc.
 Clinical features of mania
  • Elation of mood
  • Great deals of energy (boundless energy)
  • Usually restless and over active
  • Poor concentration and easily destructed by other activities
  • Patients have high appetite for food and drinks but usually have no time to eat since they lack concentration
  • Increased urge for sex (high libido)
  • Excessive involvement in pleasurable activities e.g. excessive spending habits
  • Dressing is usually inappropriate with bright colours that do not match, excessive make-up and jewelery.
  • Delusions of grandeur are more pronounced
  • Over talkativeness and pressure of speech in acute forms of mania
  • Racing thoughts i.e. accelerated thinking (the speech is very fast and continuous)
  • Insight is lost
  • Sleep is disturbed and a patient may have total insomnia
  • Auditory hallucinations are very common
  • Ideas of reference are very common (when the patient feels that people are conversing about him)
Diagnosis of mania

The following features are diagnostic of mania;

  1. Abnormally elevated mood and irritability
  2. Grandiosity (over rating one’s self)
  3. Boundless energy
  4. Over activity
  5. Over talkativeness
  6. Racing of thoughts
  7. Poor concentration and easily destructed.

Management

Hypomanic can be managed at home if there is someone to assist them take their medications

  1. Hospitalization:  If the patient is too excited, is a public nonsense, not taking care of himself e.t.c. then  admission to mental health hospital is very essential.
  1. Establishment of therapeutic relationship is very important because, it`s the key to the nursing care.
  2. If the patient is very excited, restless and unable to be calm down by the verbal instruction of the care team, a tranquilizer or a sedative such as chlorpromazine 100-200mg or Haldol 5-10mg by injection are administered
  3. Reduce the dosage and frequency as the symptom subsides.
  4. Short simple direct answers should be given when a patient asks questions.
  5. Ensure a low stimuli of the patient`s environment.
  6. Remove all the dangerous particles like iron bars, sharp instruments, easily portable stone etc that the patient can use to harm himself and others.
  7. Supervise and maintain personal hygiene.
  8. Special attention must be given to patient’s diet because a patient is usually too busy to eat because of hyperactivity and restlessness. diet rich in carbohydrates,  proteins with a lot of fluids is recommended.
  9. Observe the patient behaviors, toilet habits, eating habits, steep etc

DRUG TREATMENT

To control the manic symptoms antipsychotic like Haldol or chlorpromazine  can be used.

CPZ (chlorpromazine) 100-1200mg in divided doses which may be reduced when the patient improves

  • Thioridazine 100-600mg in divide doses (it can also help to lower the patient libido)
  • Haloperidol: 5-15mg nocte for not more than to work
  • Lithium carbonates: 250-550mg doses (it is the drug of of choice in manic patients)
  • Benzelhexol (artane)

Other drug used in manic illness in

  • Carbamazepine: 100-400mg in divided doses
  • Sodium volporate: 100-1500mg in divided doses (but are usually given given in carbonates).

ELECTRO COMVULSIVE THERAPY

  • This is very good especially in manic excitement. 1 or 2 shocks a week for 6-9 weeks. ECT is very effective when given in combination with drugs.

OCCUPATIONAL THERAPY

  • Occupational therapy is very important for recovering patient and the type of occupation varies from individual patient to another.
  • Psychotherapy to the family is very helpful
  • Resettlement and good follow up system should be put in place for individual patient.
Nursing care of manic patients
  • Diet; special attention has to be given to patients diet because he is usually too busy to eat and hence may lose weight and also dehydration may occur.
  • Meals and fluids have to be given under supervision and extra nourishment may be required to compensate for extra activity.
  • Care has to be taken to ensure that the patient dresses well
  • Supervision and directions to maintain personal hygiene like bathing, oral hygiene is essential.
  • one nurse has to be assigned to the over active patient so as to improve his confidence in her
  • Maintain a low level of stimuli to the patient environment i.e. Factors like noise and bright colours should be avoided in the ward otherwise the ward should be quiet and pleasant.
  • observe patients behaviour frequently and report any changes
  • remove any dangerous objects from the patients environment that can be used to harm self or others during times of agitation
  • Injuries attained by the patient because of his hyperactivity have to be attended to.

Prognosis

  • If well treated, most episodes resolve within three months and rarely last for more than 6months
  • There is risk of reoccurrence if the disorder begins before 30years of age
  • Studies have revealed that 10-20% of the sufferers have had 3 episodes of depression before developing mania
  • The prognosis of mania is far better than that of schizophrenia

Bipolar Affective Disorder Read More »

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